Provider Demographics
NPI:1790960102
Name:EMMANUEL RIDGE HOME CARE AGENCY INC
Entity Type:Organization
Organization Name:EMMANUEL RIDGE HOME CARE AGENCY INC
Other - Org Name:EMMANUEL RIDGE HOMEMAKER SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BEATRICE
Authorized Official - Middle Name:A
Authorized Official - Last Name:EZEM
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CM, CLNC
Authorized Official - Phone:601-927-9839
Mailing Address - Street 1:2073 HIGHWAY 49 S
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-9422
Mailing Address - Country:US
Mailing Address - Phone:601-709-3304
Mailing Address - Fax:601-709-3307
Practice Address - Street 1:2073 HIGHWAY 49 S
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-9422
Practice Address - Country:US
Practice Address - Phone:601-709-3304
Practice Address - Fax:601-709-3307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS03630719376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03630719Medicaid