Provider Demographics
NPI:1285859041
Name:RIDGEWOOD RECOVERY, INC.
Entity Type:Organization
Organization Name:RIDGEWOOD RECOVERY, INC.
Other - Org Name:THE SUPERIOR TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-392-9300
Mailing Address - Street 1:1507 TOWER AVE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-2532
Mailing Address - Country:US
Mailing Address - Phone:715-392-9300
Mailing Address - Fax:715-392-8041
Practice Address - Street 1:1507 TOWER AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2532
Practice Address - Country:US
Practice Address - Phone:715-392-9300
Practice Address - Fax:715-392-8041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIOUTPATIENT-1926251S00000X
WI1926261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42252200Medicaid