Healthcare Provider Details

I. General information

NPI: 1033689385
Provider Name (Legal Business Name): LOCUST RIDGE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12745 ELM CORNER RD
WILLIAMSBURG OH
45176-9621
US

IV. Provider business mailing address

15 AMERICA AVE UNIT 304
LAKEWOOD NJ
08701-4582
US

V. Phone/Fax

Practice location:
  • Phone: 937-444-2920
  • Fax: 937-444-1009
Mailing address:
  • Phone: 513-487-7479
  • Fax: 732-276-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: HAYLEY B WILLIAMS
Title or Position: ATTORNEY
Credential:
Phone: 216-706-3936