Provider Demographics
NPI:1851474274
Name:RIDGEWOOD RLC LLC
Entity Type:Organization
Organization Name:RIDGEWOOD RLC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:252-946-9570
Mailing Address - Street 1:PO BOX 1868
Mailing Address - Street 2:1624 HIGHLAND DRIVE
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889
Mailing Address - Country:US
Mailing Address - Phone:252-946-9570
Mailing Address - Fax:252-946-3715
Practice Address - Street 1:1624 HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889
Practice Address - Country:US
Practice Address - Phone:252-946-9570
Practice Address - Fax:252-946-3715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0387314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00966OtherBLUE CROSS BLUE SHIELD
NC3406346OtherMEDICAID ICF
NC3415228Medicaid
NC345228Medicare ID - Type Unspecified