Provider Demographics
NPI:1124421847
Name:RIDGECREST MEDICAL LLC
Entity type:Organization
Organization Name:RIDGECREST MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-353-1152
Mailing Address - Street 1:1907 W MORRIS BLVD
Mailing Address - Street 2:SUITE 300A
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-3860
Mailing Address - Country:US
Mailing Address - Phone:423-353-1152
Mailing Address - Fax:423-353-1157
Practice Address - Street 1:1907 W MORRIS BLVD
Practice Address - Street 2:SUITE 300A
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813-3860
Practice Address - Country:US
Practice Address - Phone:423-353-1152
Practice Address - Fax:423-353-1157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN962207Q00000X, 208000000X, 207R00000X
TN19037363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty