Provider Demographics
NPI:1407280720
Name:RIDGEWOOD MANOR
Entity Type:Organization
Organization Name:RIDGEWOOD MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-607-6874
Mailing Address - Street 1:10038 215TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-8519
Mailing Address - Country:US
Mailing Address - Phone:763-607-6874
Mailing Address - Fax:267-350-9164
Practice Address - Street 1:10038 215TH AVE NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-8519
Practice Address - Country:US
Practice Address - Phone:763-607-6874
Practice Address - Fax:267-350-9164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1066808-1-AFC311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home