Healthcare Provider Details

I. General information

NPI: 1851474274
Provider Name (Legal Business Name): RIDGEWOOD RLC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2006
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 HIGHLAND DRIVE
WASHINGTON NC
27889
US

IV. Provider business mailing address

PO BOX 1868 1624 HIGHLAND DRIVE
WASHINGTON NC
27889
US

V. Phone/Fax

Practice location:
  • Phone: 252-946-9570
  • Fax: 252-946-3715
Mailing address:
  • Phone: 252-946-9570
  • Fax: 252-946-3715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0387
License Number StateNC

VIII. Authorized Official

Name: MR. MICHAEL L KELLY
Title or Position: ADMINISTRATOR
Credential: NHA
Phone: 252-946-9570