Provider Demographics
NPI:1659920320
Name:PHS WALNUT RIDGE LLC
Entity Type:Organization
Organization Name:PHS WALNUT RIDGE LLC
Other - Org Name:PHS WALNUT RIDGE LLC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-631-6120
Mailing Address - Street 1:1703 CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325
Mailing Address - Country:US
Mailing Address - Phone:651-631-6450
Mailing Address - Fax:651-631-6122
Practice Address - Street 1:1703 CAMPUS DRIVE
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325
Practice Address - Country:US
Practice Address - Phone:651-631-6450
Practice Address - Fax:651-631-6122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-05
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility