Provider Demographics
NPI:1265433767
Name:EBENEZER RIDGES
Entity type:Organization
Organization Name:EBENEZER RIDGES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-898-8410
Mailing Address - Street 1:13820 COMMUNITY DR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4519
Mailing Address - Country:US
Mailing Address - Phone:952-898-8400
Mailing Address - Fax:952-898-8450
Practice Address - Street 1:13820 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4519
Practice Address - Country:US
Practice Address - Phone:952-898-8400
Practice Address - Fax:952-898-8450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328249314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN328249OtherSTATE LICENSE
MN834243100Medicaid
MN245213Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER