Provider Demographics
NPI:1053282020
Name:MORAINE RIDGE LLC
Entity type:Organization
Organization Name:MORAINE RIDGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORRIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RYCZEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-468-3111
Mailing Address - Street 1:2929 SAINT ANTHONY DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5878
Mailing Address - Country:US
Mailing Address - Phone:920-468-3111
Mailing Address - Fax:920-593-1462
Practice Address - Street 1:2929 SAINT ANTHONY DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5878
Practice Address - Country:US
Practice Address - Phone:920-468-3111
Practice Address - Fax:920-593-1462
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MORAINE RIDGE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility