Healthcare Provider Details

I. General information

NPI: 1669887352
Provider Name (Legal Business Name): DIVERSICARE OF RIVERSIDE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2014
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 WEISENBORN RD
SAINT JOSEPH MO
64507-2527
US

IV. Provider business mailing address

1616 WEISENBORN RD
SAINT JOSEPH MO
64507-2527
US

V. Phone/Fax

Practice location:
  • Phone: 816-232-9874
  • Fax: 816-364-4283
Mailing address:
  • Phone: 816-232-9874
  • Fax: 816-364-4283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number042402
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number042401
License Number StateMO

VIII. Authorized Official

Name: MATTHEW J WEISHAAR
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 615-771-7575