MEDICARE: RIVER BLUFF OF CAHOKIA NURSING & REHABILITATION CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3140N1450X	Pediatric Skilled Nursing Facility	0045005	IL

General Provider Information

NPI Number	:	1275589822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER BLUFF OF CAHOKIA NURSING & REHABILITATION CENTER LLC

Provider Business Mailing Address
First Line	:	3354 JEROME LN
Second Line	:
City	:	CAHOKIA
State	:	IL
Zip	:	62206-2604
Country	:	US
Telephone Number	:	618-337-9823
Fax Number	:	618-332-1811

Provider Business Practice Location Address
First Line	:	3354 JEROME LN
Second Line	:
City	:	CAHOKIA
State	:	IL
Zip	:	62206-2604
Country	:	US
Telephone Number	:	618-337-9823
Fax Number	:	618-332-1811

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. KENYA MARIE WASHINGTON
Credential	:
Telephone Number	:	618-337-9823

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	08/22/2020

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