Provider Demographics
NPI:1700027570
Name:FLINT RIDGE VILLAGE LLC
Entity Type:Organization
Organization Name:FLINT RIDGE VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER / CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-344-0388
Mailing Address - Street 1:65 MCMILLEN DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-3648
Mailing Address - Country:US
Mailing Address - Phone:740-344-0388
Mailing Address - Fax:740-344-0345
Practice Address - Street 1:65 MCMILLEN DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-3648
Practice Address - Country:US
Practice Address - Phone:740-344-0388
Practice Address - Fax:740-344-0345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253Z00000X253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care