Healthcare Provider Details

I. General information

NPI: 1952320111
Provider Name (Legal Business Name): RIVERSIDE ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 W COLLEGE ST
BAINBRIDGE GA
39819-6400
US

IV. Provider business mailing address

1151 W COLLEGE ST
BAINBRIDGE GA
39819-6400
US

V. Phone/Fax

Practice location:
  • Phone: 229-248-1116
  • Fax: 229-248-4115
Mailing address:
  • Phone: 229-248-1116
  • Fax: 229-248-4115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateGA

VIII. Authorized Official

Name: CHRISTOPHER BROGDON
Title or Position: MANAGER
Credential:
Phone: 770-650-7086