Provider Demographics
NPI:1174817712
Name:RIVERSIDE HEALTHCARE, INC.
Entity Type:Organization
Organization Name:RIVERSIDE HEALTHCARE, INC.
Other - Org Name:HILLCREST HEALTH CARE CENTER AND MICA HILL ESTATES ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MS
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:2121 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:HAWARDEN
Mailing Address - State:IA
Mailing Address - Zip Code:51023-1334
Mailing Address - Country:US
Mailing Address - Phone:712-551-1074
Mailing Address - Fax:712-551-2393
Practice Address - Street 1:2121 AVENUE L
Practice Address - Street 2:
Practice Address - City:HAWARDEN
Practice Address - State:IA
Practice Address - Zip Code:51023-1334
Practice Address - Country:US
Practice Address - Phone:712-551-1074
Practice Address - Fax:712-551-2393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA310400000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA165245Medicare Oscar/Certification