MEDICARE: RIDGECREST NH, LLC

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	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)
2	314000000X	Skilled Nursing Facility	SNF1475096	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477558039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIDGECREST NH, LLC

Provider Business Mailing Address
First Line	:	1200 N STONE ST
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-2511
Country	:	US
Telephone Number	:	386-734-4334
Fax Number	:	386-736-2118

Provider Business Practice Location Address
First Line	:	1200 N STONE ST
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-2511
Country	:	US
Telephone Number	:	386-734-4334
Fax Number	:	386-736-2118

Authorized Official
Title or Position	:	CEO
Name	:	MOSHE SCHEINER
Credential	:
Telephone Number	:	813-557-6200

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	06/27/2021

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