Healthcare Provider Details

I. General information

NPI: 1134305436
Provider Name (Legal Business Name): WOODRIDGE NORTHEAST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N 7TH ST
WEST MEMPHIS AR
72301
US

IV. Provider business mailing address

2520 NORTHWINDS PKWY STE 550
ALPHARETTA GA
30009-2236
US

V. Phone/Fax

Practice location:
  • Phone: 870-394-7100
  • Fax: 870-394-7111
Mailing address:
  • Phone: 470-554-7902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number213
License Number StateAR

VIII. Authorized Official

Name: ROCHELLE GERBER
Title or Position: AVP OF ADMINISTRATIVE SERVICES
Credential:
Phone: 470-554-7903