Provider Demographics
NPI:1649255761
Name:EAST RIDGE RETIREMENT VILLAGE, INC.
Entity type:Organization
Organization Name:EAST RIDGE RETIREMENT VILLAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY OF BOARD OF DIRECTORS
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-238-9617
Mailing Address - Street 1:19225 SW 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-8984
Mailing Address - Country:US
Mailing Address - Phone:305-238-2623
Mailing Address - Fax:305-256-3516
Practice Address - Street 1:19225 SW 87TH AVE
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-8984
Practice Address - Country:US
Practice Address - Phone:305-238-2623
Practice Address - Fax:305-256-3516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL6091310400000X
FLSNF1136096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022878800Medicaid
FL105508Medicare Oscar/Certification