Provider Demographics
NPI:1174018956
Name:RIDGE, EILEEN
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:RIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 GLENWAY ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121-4109
Mailing Address - Country:US
Mailing Address - Phone:857-540-0999
Mailing Address - Fax:
Practice Address - Street 1:105 VICTORY RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3518
Practice Address - Country:US
Practice Address - Phone:617-371-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN233923163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health