Healthcare Provider Details

I. General information

NPI: 1295380467
Provider Name (Legal Business Name): RIVERSIDE ELITE ADVANTAGE CARE HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17085 BIRCH HILL RD
RIVERSIDE CA
92504-8823
US

IV. Provider business mailing address

31491 SHADOW RIDGE DR
MENIFEE CA
92584-8213
US

V. Phone/Fax

Practice location:
  • Phone: 951-398-7680
  • Fax:
Mailing address:
  • Phone: 951-850-1088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JAMIE TENG
Title or Position: NURSING ADMINISTRATOR MANAGER
Credential:
Phone: 951-850-1088