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General NPI Number Information
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NPI Number | 1831364835
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Entity Type | Organization
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Legal Business Name | RIDGE CREEK, INC.
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Dates
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Enumeration Date | 04/30/2008
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Last Update Date | 04/30/2008
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Provider Practice Location Address
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Address Line | 830 HIDDEN LAKE RD
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City | DAHLONEGA
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State | GA
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Zip | 30533-1875
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Country | US
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Telephone | 706-864-4730
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Fax |
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Provider Business Mailing Address
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Address Line | 830 HIDDEN LAKE RD
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City | DAHLONEGA
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State | GA
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Zip | 30533-1875
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Country | US
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Telephone | 706-864-4730
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. LEN BUCCELLATO
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Credential | PH.D.
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Telephone | 706-864-4730
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | CCI001713
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License Number State | GA
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