Healthcare Provider Details

I. General information

NPI: 1922164458
Provider Name (Legal Business Name): RIVERSIDE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 04/28/2008
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: 815-933-1671
  • Fax:
Mailing address:
  • Phone: 815-933-1671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number980844
License Number StateIL

VIII. Authorized Official

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