=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255740189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERCREST SPECIALTY HOSPITAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2014
-----------------------------------------------------
Last Update Date | 08/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1625 E JEFFERSON BLVD
-----------------------------------------------------
City | MISHAWAKA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46545-7103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-255-1400
-----------------------------------------------------
Fax | 574-255-1840
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 W JEFFERSON BLVD STE 600
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-255-1400
-----------------------------------------------------
Fax | 574-255-1840
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORP BOD
-----------------------------------------------------
Name | CHRISTY KELTNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-319-6552
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------