Basic Information
| Provider Information | |||||||||
| NPI: | 1568579993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERVIEW HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ROLLING MEADOWS HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 RENNAKER ST | ||||||||
| Address2: | |||||||||
| City: | LA FONTAINE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469409045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659812081 | ||||||||
| FaxNumber: | 7659814954 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 RENNAKER ST | ||||||||
| Address2: | |||||||||
| City: | LA FONTAINE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469409045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7659812081 | ||||||||
| FaxNumber: | 7659814954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 05/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | GIBSON | ||||||||
| AuthorizedOfficialFirstName: | CULLEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7656645400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100289950B | 05 | IN | MEDICAID |