Healthcare Provider Details

I. General information

NPI: 1629013404
Provider Name (Legal Business Name): RIVERLANDS HOME GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1980 RIVER ROAD
LUTCHER LA
70071
US

IV. Provider business mailing address

1980 RIVER ROAD
LUTCHER LA
70071
US

V. Phone/Fax

Practice location:
  • Phone: 225-869-5725
  • Fax: 225-869-4009
Mailing address:
  • Phone: 225-869-5725
  • Fax: 225-869-4009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1017
License Number StateLA

VIII. Authorized Official

Name: MR. STEVEN D BOULWARE
Title or Position: AUTHORIZED REPRESENTATIVE
Credential:
Phone: 985-855-4424