Healthcare Provider Details

I. General information

NPI: 1184848202
Provider Name (Legal Business Name): CEDAR RIDGE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 THICKSTEN DR
ALMA AR
72921
US

IV. Provider business mailing address

107 THICKSTEN DR P.O. BOX 2389
ALMA AR
72921
US

V. Phone/Fax

Practice location:
  • Phone: 479-632-3813
  • Fax: 479-632-8986
Mailing address:
  • Phone: 479-632-3813
  • Fax: 479-632-8986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number04-G030
License Number StateAR

VIII. Authorized Official

Name: MS. TONI D WILSON
Title or Position: EXECUTIVE DIRECTOR
Credential: M.ED
Phone: 479-632-3813