Provider Demographics
NPI:1063486363
Name:LAKE RIDGE NEUROLOGICAL
Entity type:Organization
Organization Name:LAKE RIDGE NEUROLOGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ORLANDO
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:RICALDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-885-9866
Mailing Address - Street 1:SUITE B 103 OMNI DRIVE
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-9448
Mailing Address - Country:US
Mailing Address - Phone:864-885-9866
Mailing Address - Fax:864-888-8307
Practice Address - Street 1:SUITE B 103 OMNI DRIVE
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9448
Practice Address - Country:US
Practice Address - Phone:864-885-9866
Practice Address - Fax:864-888-8307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1724Medicaid
SCGP1724Medicaid