Healthcare Provider Details

I. General information

NPI: 1619144870
Provider Name (Legal Business Name): RIVERSIDE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N WALL ST
KANKAKEE IL
60901-2901
US

IV. Provider business mailing address

350 N WALL ST
KANKAKEE IL
60901-2901
US

V. Phone/Fax

Practice location:
  • Phone: 815-935-7256
  • Fax: 815-935-7490
Mailing address:
  • Phone: 815-935-7256
  • Fax: 815-935-7490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number0002014
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number0002014
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number0002014
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number0002014
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number0002014
License Number StateIL

VIII. Authorized Official

Name: MR. BILL W DOUGLAS
Title or Position: VICE PRESIDENT AND CFO
Credential:
Phone: 815-935-7256