Provider Demographics
NPI:1861484271
Name:CHRISTIAN RETIREMENT HOMES, INC.
Entity Type:Organization
Organization Name:CHRISTIAN RETIREMENT HOMES, INC.
Other - Org Name:RIDGECREST VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BERT
Authorized Official - Middle Name:
Authorized Official - Last Name:VIGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-391-3430
Mailing Address - Street 1:4130 NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-4243
Mailing Address - Country:US
Mailing Address - Phone:563-391-3430
Mailing Address - Fax:563-388-3287
Practice Address - Street 1:4130 NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-4243
Practice Address - Country:US
Practice Address - Phone:563-391-3430
Practice Address - Fax:563-388-3287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0139310400000X, 311500000X
IAN0407313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0803403Medicaid
IA165409Medicare Oscar/Certification