Basic Information
| Provider Information | |||||||||
| NPI: | 1417251323 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVER FALLS HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRACE HEALTHCARE OF RIVER FALLS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1663 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540221571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154266000 | ||||||||
| FaxNumber: | 7154257728 | ||||||||
| Practice Location | |||||||||
| Address1: | 1663 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540221571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154266000 | ||||||||
| FaxNumber: | 7154257728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2011 | ||||||||
| LastUpdateDate: | 01/06/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARK DANKS | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4233081845 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 3095 | WI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 20192800 | 05 | WI | MEDICAID |