MEDICARE: RIDGEWAY FAMILY BUSINESS L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	101449	OTHER	AK	STATE OF ALASKA RESIDENTIAL LICENSE

General Provider Information

NPI Number	:	1144985961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIDGEWAY FAMILY BUSINESS L.L.C.

Provider Business Mailing Address
First Line	:	6239 E 12TH AVE
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99504-2335
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6239 E 12TH AVE
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99504-2335
Country	:	US
Telephone Number	:	907-310-5310
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	LONNIE RIDGEWAY
Credential	:
Telephone Number	:	907-310-5310

Provider Enumeration Date	:	11/05/2021
Last Update Date	:	11/05/2021

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