Provider Demographics
NPI:1336971233
Name:STONEY RIDGE VILLAGE I LLC
Entity type:Organization
Organization Name:STONEY RIDGE VILLAGE I LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EDERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-708-3503
Mailing Address - Street 1:445 CENTRAL AVE UNIT 215
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-2021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25023 BOTHWELL PARK RD
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-0084
Practice Address - Country:US
Practice Address - Phone:660-827-3993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-19
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility