Provider Demographics
NPI:1134124415
Name:RIVERSIDE CONGREGATIONAL HOMES
Entity Type:Organization
Organization Name:RIVERSIDE CONGREGATIONAL HOMES
Other - Org Name:PLYMOUTH TOWER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V.P. OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-257-5100
Mailing Address - Street 1:3401 LEMON ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-2817
Mailing Address - Country:US
Mailing Address - Phone:951-686-8202
Mailing Address - Fax:951-784-1508
Practice Address - Street 1:3401 LEMON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-2817
Practice Address - Country:US
Practice Address - Phone:951-686-8202
Practice Address - Fax:951-784-1508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT18656FMedicaid
CA555613Medicare ID - Type UnspecifiedMEDICARE ID