MEDICARE: RIDGLEA SENIOR LIVING 2015, 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	310400000X	Assisted Living Facility		TX

General Provider Information

NPI Number	:	1609378603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIDGLEA SENIOR LIVING 2015, LLC

Provider Business Mailing Address
First Line	:	777 MAIN ST STE 2300
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-5304
Country	:	US
Telephone Number	:	817-851-5805
Fax Number	:

Provider Business Practice Location Address
First Line	:	4109 WESTRIDGE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7410
Country	:	US
Telephone Number	:	817-386-8251
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS
Name	:	TANNER STIERWALT
Credential	:
Telephone Number	:	817-851-5805

Provider Enumeration Date	:	03/06/2018
Last Update Date	:	03/06/2018

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