Healthcare Provider Details

I. General information

NPI: 1134692270
Provider Name (Legal Business Name): RIVERSIDE HEALTHCARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 W MONROE RD
SAINT LOUIS MI
48880-9736
US

IV. Provider business mailing address

30700 TELEGRAPH RD STE 2504
BINGHAM FARMS MI
48025-4571
US

V. Phone/Fax

Practice location:
  • Phone: 989-681-3852
  • Fax:
Mailing address:
  • Phone: 248-593-1990
  • Fax: 248-593-9120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: FAHIM UDDIN
Title or Position: SOLE MEMBER
Credential:
Phone: 248-593-1990