Healthcare Provider Details

I. General information

NPI: 1245224732
Provider Name (Legal Business Name): RIVERSIDE SANITARIUM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4580 PALM AVENUE
RIVERSIDE CA
92501
US

IV. Provider business mailing address

4580 PALM AVENUE
RIVERSIDE CA
92501
US

V. Phone/Fax

Practice location:
  • Phone: 951-684-7701
  • Fax: 951-684-2236
Mailing address:
  • Phone: 951-684-7701
  • Fax: 310-574-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number250000119
License Number StateCA

VIII. Authorized Official

Name: JACOB WINTNER
Title or Position: MANAGER
Credential:
Phone: 323-651-1808