Provider Demographics
NPI:1851504385
Name:MELLON RIDGE, INC.
Entity Type:Organization
Organization Name:MELLON RIDGE, INC.
Other - Org Name:PEEBLES RESIDENT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLERAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-614-0160
Mailing Address - Street 1:22021 BROOKPARK RD
Mailing Address - Street 2:STE 123
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3100
Mailing Address - Country:US
Mailing Address - Phone:440-614-0160
Mailing Address - Fax:440-614-0168
Practice Address - Street 1:25773 STATE ROUTE 41
Practice Address - Street 2:
Practice Address - City:PEEBLES
Practice Address - State:OH
Practice Address - Zip Code:45660-8953
Practice Address - Country:US
Practice Address - Phone:937-587-5414
Practice Address - Fax:440-614-0168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1955310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility