Provider Demographics
NPI:1275521627
Name:SLO RIDGECREST LLC
Entity Type:Organization
Organization Name:SLO RIDGECREST LLC
Other - Org Name:RIDGECREST HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:HELEN
Authorized Official - Last Name:SWEET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-797-9948
Mailing Address - Street 1:16640 N 38TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2103
Mailing Address - Country:US
Mailing Address - Phone:602-482-6671
Mailing Address - Fax:602-482-3541
Practice Address - Street 1:16640 N 38TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2103
Practice Address - Country:US
Practice Address - Phone:602-482-6671
Practice Address - Fax:602-482-3541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNCI2651313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ924771Medicaid
AZ035125Medicare Oscar/Certification