Provider Demographics
NPI:1902804156
Name:CEDAR RIDGE INN, INC.
Entity Type:Organization
Organization Name:CEDAR RIDGE INN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISSI
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-516-1404
Mailing Address - Street 1:800 SAGUARO TRL
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9632
Mailing Address - Country:US
Mailing Address - Phone:505-598-6000
Mailing Address - Fax:505-598-6009
Practice Address - Street 1:800 SAGUARO TRL
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9632
Practice Address - Country:US
Practice Address - Phone:505-598-6000
Practice Address - Fax:505-598-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1007314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28985010Medicaid
325113Medicare UPIN