Provider Demographics
NPI:1295904548
Name:CARDINAL RIDGE RESIDENTIAL CARE
Entity type:Organization
Organization Name:CARDINAL RIDGE RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:CECILIA
Authorized Official - Last Name:KENNEDYDART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-743-9289
Mailing Address - Street 1:817 CIRCLE RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-3621
Mailing Address - Country:US
Mailing Address - Phone:920-743-9289
Mailing Address - Fax:920-743-4445
Practice Address - Street 1:817 CIRCLE RIDGE PL
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-3621
Practice Address - Country:US
Practice Address - Phone:920-743-9289
Practice Address - Fax:920-743-4445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility