=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609378603
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIDGLEA SENIOR LIVING 2015, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2018
-----------------------------------------------------
Last Update Date | 03/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4109 WESTRIDGE AVE
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-7410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-386-8251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 777 MAIN ST STE 2300
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76102-5304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-851-5805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS
-----------------------------------------------------
Name | TANNER STIERWALT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-851-5805
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------