Provider Demographics
NPI:1093006074
Name:AMBER RIDGE ASSISTED LIVING, INC
Entity Type:Organization
Organization Name:AMBER RIDGE ASSISTED LIVING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:JAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-322-3501
Mailing Address - Street 1:107 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-2140
Mailing Address - Country:US
Mailing Address - Phone:563-322-3501
Mailing Address - Fax:
Practice Address - Street 1:107 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-2140
Practice Address - Country:US
Practice Address - Phone:563-659-1678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0089310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility