Basic Information
Provider Information | |||||||||
NPI: | 1801067269 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MSPF-IV RIDGEMAR OE, LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE PLAZA AT RIDGEMAR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3811 TURTLE CREEK BLVD | ||||||||
Address2: | SUITE #1850 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752194402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146514050 | ||||||||
FaxNumber: | 2146514001 | ||||||||
Practice Location | |||||||||
Address1: | 6600 LANDS END CT | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761162100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8176651971 | ||||||||
FaxNumber: | 8176651977 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/13/2008 | ||||||||
LastUpdateDate: | 04/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RONCK | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2146514050 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 116802 | TX | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 5470 | 01 | TX | MEDICAID VENDOR | OTHER |