Basic Information
| Provider Information | |||||||||
| NPI: | 1710166558 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFEHOUSE RIVERSIDE OPERATIONS, LLC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVERSIDE HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8781 LAKEVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925095969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516851531 | ||||||||
| FaxNumber: | 9516854544 | ||||||||
| Practice Location | |||||||||
| Address1: | 8781 LAKEVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925095969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516851531 | ||||||||
| FaxNumber: | 9516854544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BANSAL | ||||||||
| AuthorizedOfficialFirstName: | MANEESH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5629249618 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFEHOUSE HEALTH SERVICES, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.