Basic Information
| Provider Information | |||||||||
| NPI: | 1356308399 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE HEALTH CARE CENTER | ||||||||
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| OtherOrganizationName: | RIVERSIDE HEALTH & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 HAZELTINE BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHASKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553181009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9523618000 | ||||||||
| FaxNumber: | 9523618058 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 E BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067210680 | ||||||||
| FaxNumber: | 4067219788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 04/02/2017 | ||||||||
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| AuthorizedOfficialLastName: | WEICHERT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN OF THE BOARD | ||||||||
| AuthorizedOfficialTelephone: | 9523618000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 9926 | MT | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0532181 | 05 | MT | MEDICAID | 0311402 | 05 | MT | MEDICAID | 0344123 | 05 | MT | MEDICAID | 4076-2 | 01 | BCBS OF MONTANA | OTHER | 0344110 | 05 | MT | MEDICAID | 612105 | 05 | MT | MEDICAID | 0212953 | 05 | MT | MEDICAID |