Provider Demographics
NPI:1114200664
Name:HOUSE ON THE RIVIERA ASSISTED LIVING
Entity Type:Organization
Organization Name:HOUSE ON THE RIVIERA ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:EVE
Authorized Official - Last Name:LA PLANTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-855-1133
Mailing Address - Street 1:190 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5735
Mailing Address - Country:US
Mailing Address - Phone:928-855-1133
Mailing Address - Fax:928-855-1133
Practice Address - Street 1:190 RIVIERA DR.
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-855-1133
Practice Address - Fax:928-855-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8084H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ527150Medicaid