Basic Information
| Provider Information | |||||||||
| NPI: | 1912299660 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER LODGE ASSISTED LIVING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 217 LAKEWOOD RD | ||||||||
| Address2: | |||||||||
| City: | VAN BUREN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729568120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794719797 | ||||||||
| FaxNumber: | 4794717559 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 RIVERLODGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706070902 | ||||||||
| FaxNumber: | 8706070905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2011 | ||||||||
| LastUpdateDate: | 05/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | HIGHTOWER | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | PARKER | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4794719797 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 049 | AR | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 185308794 | 05 | AR | MEDICAID |