Healthcare Provider Details

I. General information

NPI: 1912174756
Provider Name (Legal Business Name): RIDGELY RETREAT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 RIDGELY AVE
ANNAPOLIS MD
21401-1303
US

IV. Provider business mailing address

203 RIDGELY AVE
ANNAPOLIS MD
21401-1303
US

V. Phone/Fax

Practice location:
  • Phone: 443-433-0462
  • Fax: 443-433-0491
Mailing address:
  • Phone: 443-433-0462
  • Fax: 443-433-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number476282
License Number StateMD

VIII. Authorized Official

Name: MRS. ANDREA LEE LICHTENSTEIN
Title or Position: OWNER
Credential: RN
Phone: 443-433-0462