Healthcare Provider Details

I. General information

NPI: 1467116061
Provider Name (Legal Business Name): RIVER KETCHERSIDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 MUNICIPAL DR
CARTERVILLE IL
62918-2042
US

IV. Provider business mailing address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

V. Phone/Fax

Practice location:
  • Phone: 855-608-3560
  • Fax: 618-956-9349
Mailing address:
  • Phone: 314-652-4100
  • Fax: 314-845-5016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150109270
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: