Basic Information
| Provider Information | |||||||||
| NPI: | 1912622499 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 N WALL ST | ||||||||
| Address2: | |||||||||
| City: | KANKAKEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609012901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159357256 | ||||||||
| FaxNumber: | 8159357490 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 FITNESS DR | ||||||||
| Address2: | |||||||||
| City: | BOURBONNAIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609149584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159366515 | ||||||||
| FaxNumber: | 8159366517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2022 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | VILT | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | KIM | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8159357542 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVERSIDE MEDICAL CENTER | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | N | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator | 174H00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Health Educator |
No ID Information.