1134692270 NPI number — RIVERSIDE HEALTHCARE CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134692270 NPI number — RIVERSIDE HEALTHCARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE HEALTHCARE CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RIVERSIDE HEALTHCARE CENTER
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134692270
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30700 TELEGRAPH RD STE 2504
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BINGHAM FARMS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-4571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-593-1990
Provider Business Mailing Address Fax Number:
248-593-9120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1149 W MONROE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48880-9736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-681-3852
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
UDDIN
Authorized Official First Name:
FAHIM
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
248-593-1990

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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