1639328909 NPI number — RIVERSIDE NURSING HOME 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 1639328909 NPI number — RIVERSIDE NURSING HOME LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE NURSING HOME 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:
Provider Other Organization Name Type Code:
6
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:
1639328909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 S GRAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71202-4152
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-388-3200
Provider Business Mailing Address Fax Number:
318-388-2909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001 S GRAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71202-4152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-388-3200
Provider Business Practice Location Address Fax Number:
318-388-2909
Provider Enumeration Date:
09/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DELATTE
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
225-664-6697

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  58 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1517810 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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