=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750764767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONGREGATE LIVING HOME RIVERSIDE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2015
-----------------------------------------------------
Last Update Date | 07/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 951 CORNFLOWER DR
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92545-6370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-396-2557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 951 CORNFLOWER DR
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92545-6370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ARMINE BABAYAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-396-2557
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------