Basic Information
| Provider Information | |||||||||
| NPI: | 1851474274 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIDGEWOOD RLC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1868 | ||||||||
| Address2: | 1624 HIGHLAND DRIVE | ||||||||
| City: | WASHINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529469570 | ||||||||
| FaxNumber: | 2529463715 | ||||||||
| Practice Location | |||||||||
| Address1: | 1624 HIGHLAND DRIVE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529469570 | ||||||||
| FaxNumber: | 2529463715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2006 | ||||||||
| LastUpdateDate: | 11/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2529469570 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | NHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0387 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00966 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 3406346 | 01 | NC | MEDICAID ICF | OTHER | 3415228 | 05 | NC | MEDICAID |