Provider Demographics
NPI:1972634905
Name:KERNER RIDGE ASSISTED LIVING LLC
Entity type:Organization
Organization Name:KERNER RIDGE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:NEAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-993-7555
Mailing Address - Street 1:853 OLD WINSTON RD STE 118
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8781
Mailing Address - Country:US
Mailing Address - Phone:336-993-7555
Mailing Address - Fax:336-993-6111
Practice Address - Street 1:250 HOPKINS RD
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-9314
Practice Address - Country:US
Practice Address - Phone:336-993-1881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804126Medicaid