Healthcare Provider Details

I. General information

NPI: 1154345676
Provider Name (Legal Business Name): RIVERSIDE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14588 W HIGHWAY 22 RIVERSIDE FOUNDATION
LINCOLNSHIRE IL
60069
US

IV. Provider business mailing address

14588 W HIGHWAY 22 RIVERSIDE FOUNDATION
LINCOLNSHIRE IL
60069
US

V. Phone/Fax

Practice location:
  • Phone: 847-634-3973
  • Fax: 847-634-0227
Mailing address:
  • Phone: 847-634-3973
  • Fax: 847-634-0227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number0022988
License Number StateIL

VIII. Authorized Official

Name: MR. PETE MULE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 847-634-3973