Mallard Ridge LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

HAL 029 007 Issued in NC

Legal business name

MALLARD RIDGE LLC

Practice address

851 Old Winston Rd
Kernersville, NC 27284-8780

Phone

(336) 993-7555

NPI assigned

Mar 9, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Tracy Hennessee

Title

Executive Director

Phone

(336) 775-2205

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173398400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1861523896",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "851 OLD WINSTON RD",
            "city": "KERNERSVILLE",
            "state": "NC",
            "postal_code": "272848780",
            "telephone_number": "336-775-2205"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "851 OLD WINSTON RD",
            "city": "KERNERSVILLE",
            "state": "NC",
            "postal_code": "272848780",
            "telephone_number": "336-993-7555"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MALLARD RIDGE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-09",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "HENNESSEE",
        "authorized_official_first_name": "TRACY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "336-775-2205",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "NC",
            "license": "HAL 029 007",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7805429",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kelsey Mae Maffett Gibson, NP
• Michael Brent Magnet, PHARM. D.
• Samoya C Majors
• Sarah Makari
• Kristen Banks Malinowski, PMHNP
• Palak Hitenbhai Maniar
• Ashlyn Kay Mann
• Elizabeth Blakeney Brown Mark, DPT
• Lauren Marsden, BCBA
• Jessica Lynne Marshall, D.O.

• Assisted Living Facility in Kernersville, NC
• Providers in Kernersville, NC by specialty
• Assisted Living Facility in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.