Healthcare Provider Details

I. General information

NPI: 1902804156
Provider Name (Legal Business Name): CEDAR RIDGE INN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SAGUARO TRL
FARMINGTON NM
87401-9632
US

IV. Provider business mailing address

800 SAGUARO TRL
FARMINGTON NM
87401-9632
US

V. Phone/Fax

Practice location:
  • Phone: 505-598-6000
  • Fax: 505-598-6009
Mailing address:
  • Phone: 505-598-6000
  • Fax: 505-598-6009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1007
License Number StateNM

VIII. Authorized Official

Name: MS. KRISSI ELLIOTT
Title or Position: MANAGEMENT
Credential:
Phone: 970-516-1404