Provider Demographics
NPI:1033119649
Name:RIDGEMONT TERRACE INC
Entity type:Organization
Organization Name:RIDGEMONT TERRACE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHASTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-876-4461
Mailing Address - Street 1:2051 POTTERY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-2010
Mailing Address - Country:US
Mailing Address - Phone:360-876-4461
Mailing Address - Fax:360-876-4482
Practice Address - Street 1:2051 POTTERY AVE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2010
Practice Address - Country:US
Practice Address - Phone:360-876-4461
Practice Address - Fax:360-876-4482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANH588314000000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing FacilityGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4158804Medicaid
WA4158804Medicaid