Provider Demographics
NPI:1417675471
Name:BEACON RIDGE SNF OPERATIONS LLC
Entity Type:Organization
Organization Name:BEACON RIDGE SNF OPERATIONS LLC
Other - Org Name:BEACON RIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GANZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-422-8848
Mailing Address - Street 1:102 E LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-2858
Mailing Address - Country:US
Mailing Address - Phone:918-216-1811
Mailing Address - Fax:918-514-6709
Practice Address - Street 1:102 E LINE AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-2858
Practice Address - Country:US
Practice Address - Phone:918-216-1811
Practice Address - Fax:918-514-6709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-16
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility