Basic Information
| Provider Information | |||||||||
| NPI: | 1932175791 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERVIEW HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LYONS HEALTH & LIVING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3249 E COVENANTER DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474015479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123322265 | ||||||||
| FaxNumber: | 8123340854 | ||||||||
| Practice Location | |||||||||
| Address1: | COUNTY ROAD 800 WEST | ||||||||
| Address2: | |||||||||
| City: | LYONS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474430247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126591440 | ||||||||
| FaxNumber: | 8126599995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 8123322265 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 050001441 | IN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100266760B | 05 | IN | MEDICAID |