Provider Demographics
NPI:1033508809
Name:EMMANUEL RIDGE HOUSING INC
Entity Type:Organization
Organization Name:EMMANUEL RIDGE HOUSING INC
Other - Org Name:ASSISTED/EXTENDED STAY FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEATRICE
Authorized Official - Middle Name:A
Authorized Official - Last Name:EZEM
Authorized Official - Suffix:
Authorized Official - Credentials:RN,CM,CLNC
Authorized Official - Phone:601-927-9839
Mailing Address - Street 1:750 BOLING ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-2652
Mailing Address - Country:US
Mailing Address - Phone:769-233-7439
Mailing Address - Fax:769-251-0257
Practice Address - Street 1:803 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2539
Practice Address - Country:US
Practice Address - Phone:662-705-5031
Practice Address - Fax:662-705-5034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-17
Last Update Date:2015-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS310400000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08762218Medicaid
MS03630719Medicaid
MS07123515Medicaid