Healthcare Provider Details

I. General information

NPI: 1639328909
Provider Name (Legal Business Name): RIVERSIDE NURSING HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 S GRAND ST
MONROE LA
71202-4152
US

IV. Provider business mailing address

3001 S GRAND ST
MONROE LA
71202-4152
US

V. Phone/Fax

Practice location:
  • Phone: 318-388-3200
  • Fax: 318-388-2909
Mailing address:
  • Phone: 318-388-3200
  • Fax: 318-388-2909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number58
License Number StateLA

VIII. Authorized Official

Name: KIMBERLY W DELATTE
Title or Position: CFO
Credential:
Phone: 225-664-6697