Provider Demographics
NPI:1871876003
Name:EMERALD RIDGE ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:EMERALD RIDGE ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:TEGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-378-5839
Mailing Address - Street 1:3232 N BALLARD RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8804
Mailing Address - Country:US
Mailing Address - Phone:920-574-3833
Mailing Address - Fax:920-574-3850
Practice Address - Street 1:130 BYRD AVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4079
Practice Address - Country:US
Practice Address - Phone:920-574-3833
Practice Address - Fax:920-574-3850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-23
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility