Provider Demographics
NPI:1407830144
Name:RIDGECREST RETIREMENT CENTER, LTD
Entity Type:Organization
Organization Name:RIDGECREST RETIREMENT CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-340-7155
Mailing Address - Street 1:845 PROTON RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4203
Mailing Address - Country:US
Mailing Address - Phone:210-582-3716
Mailing Address - Fax:210-582-3816
Practice Address - Street 1:1900 W HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-9729
Practice Address - Country:US
Practice Address - Phone:254-776-9681
Practice Address - Fax:254-776-7960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109995314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
455670Medicare ID - Type UnspecifiedMUTUAL OF OMAHA