MEDICARE: RIVIERA MANOR NURSING HOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	0004473	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528062098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVIERA MANOR NURSING HOME

Provider Business Mailing Address
First Line	:	490 W 16TH PL
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-3224
Country	:	US
Telephone Number	:	708-481-4444
Fax Number	:	708-481-4606

Provider Business Practice Location Address
First Line	:	490 W 16TH PL
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-3224
Country	:	US
Telephone Number	:	708-481-4444
Fax Number	:	708-481-4606

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. RICHARD S. POTEKIN
Credential	:	NONE
Telephone Number	:	708-481-4444

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	08/22/2020

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