Provider Demographics
NPI:1699926386
Name:WOODRIDGE OF TENNESSEE, LLC
Entity type:Organization
Organization Name:WOODRIDGE OF TENNESSEE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GERBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-554-7903
Mailing Address - Street 1:2520 NORTHWINDS PKWY STE 550
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-2236
Mailing Address - Country:US
Mailing Address - Phone:470-554-7903
Mailing Address - Fax:470-300-7566
Practice Address - Street 1:49 OLD HICKORY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-4551
Practice Address - Country:US
Practice Address - Phone:731-668-5880
Practice Address - Fax:731-668-5870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000002976323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1509178Medicaid