Basic Information
| Provider Information | |||||||||
| NPI: | 1861854242 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERWOOD-LTC, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | RIVERWOOD HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10945 STATE BRIDGE RD | ||||||||
| Address2: | SUITE 401-470 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300228164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783812820 | ||||||||
| FaxNumber: | 6783812810 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 BACON ST | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778642575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9363489097 | ||||||||
| FaxNumber: | 9363489212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2016 | ||||||||
| LastUpdateDate: | 03/24/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOUSTON | ||||||||
| AuthorizedOfficialFirstName: | DAREN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER.CFO | ||||||||
| AuthorizedOfficialTelephone: | 6783812810 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.