Provider Demographics
NPI:1255547634
Name:TRILOGY HEALTHCARE OF GLEN RIDGE, LLC
Entity type:Organization
Organization Name:TRILOGY HEALTHCARE OF GLEN RIDGE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-412-5847
Mailing Address - Street 1:PO BOX 221648
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40252-1648
Mailing Address - Country:US
Mailing Address - Phone:502-412-5847
Mailing Address - Fax:
Practice Address - Street 1:6415 CALM RIVER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-3250
Practice Address - Country:US
Practice Address - Phone:502-297-8590
Practice Address - Fax:502-297-8766
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRILOGY OPCO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-15
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100729314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY185461Medicare Oscar/Certification