Provider Demographics
NPI:1912174756
Name:RIDGELY RETREAT LLC
Entity Type:Organization
Organization Name:RIDGELY RETREAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LICHTENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:443-433-0462
Mailing Address - Street 1:203 RIDGELY AVE
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1303
Mailing Address - Country:US
Mailing Address - Phone:443-433-0462
Mailing Address - Fax:443-433-0491
Practice Address - Street 1:203 RIDGELY AVE
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1303
Practice Address - Country:US
Practice Address - Phone:443-433-0462
Practice Address - Fax:443-433-0491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD476282174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty