Provider Demographics
NPI:1285258368
Name:RIDLEY, TICE
Entity type:Individual
Prefix:
First Name:TICE
Middle Name:
Last Name:RIDLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 406
Mailing Address - Street 2:
Mailing Address - City:BAY PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33744-0406
Mailing Address - Country:US
Mailing Address - Phone:866-410-3774
Mailing Address - Fax:727-499-7526
Practice Address - Street 1:19717 BOWER RD
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33523-6867
Practice Address - Country:US
Practice Address - Phone:773-859-9006
Practice Address - Fax:727-499-7526
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home