1952475485 NPI number — RIVERSIDE NURSING - CENTRALIA LLC

Table of content: (NPI 1952475485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952475485 NPI number — RIVERSIDE NURSING - CENTRALIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE NURSING - CENTRALIA 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:
1952475485
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1305 ALEXANDER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRALIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98531-1305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-736-2823
Provider Business Mailing Address Fax Number:
360-736-1821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 ALEXANDER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98531-1305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-736-2823
Provider Business Practice Location Address Fax Number:
360-736-1821
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
DOV
Authorized Official Middle Name:
E
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
323-678-4426

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)

  • Identifier: 4197000 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com