Healthcare Provider Details

I. General information

NPI: 1245514546
Provider Name (Legal Business Name): RIVERSIDE NURSING HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 MILLHAVEN ROAD
MONROE LA
71203-9008
US

IV. Provider business mailing address

301 VETERANS BLVD
DENHAM SPRINGS LA
70726-4722
US

V. Phone/Fax

Practice location:
  • Phone: 318-737-1117
  • Fax: 318-388-2909
Mailing address:
  • Phone: 225-664-6697
  • Fax: 225-667-2843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number957
License Number StateLA

VIII. Authorized Official

Name: KIM DELATTE
Title or Position: COMPTROLLER
Credential:
Phone: 225-664-6697