Provider Demographics
NPI:1518283381
Name:HOLLY RIDGE HEALTHCARE, INC
Entity Type:Organization
Organization Name:HOLLY RIDGE HEALTHCARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-536-5365
Mailing Address - Street 1:17826 EDISON AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1262
Mailing Address - Country:US
Mailing Address - Phone:636-536-5365
Mailing Address - Fax:636-536-4533
Practice Address - Street 1:13134 HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-9740
Practice Address - Country:US
Practice Address - Phone:573-624-4433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-19
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1518283381Medicaid