Healthcare Provider Details

I. General information

NPI: 1174603377
Provider Name (Legal Business Name): RIVERSIDE SENIOR LIVING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BUTTERFIELD TRL
KANKAKEE IL
60901-2959
US

IV. Provider business mailing address

1601 BUTTERFIELD TRL
KANKAKEE IL
60901-2959
US

V. Phone/Fax

Practice location:
  • Phone: 815-936-6500
  • Fax: 815-936-8965
Mailing address:
  • Phone: 815-936-6500
  • Fax: 815-936-8965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0040659
License Number StateIL

VIII. Authorized Official

Name: RICHARD P SCHILTZ
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 815-935-7256