Provider Demographics
NPI:1275589822
Name:RIVER BLUFF OF CAHOKIA NURSING & REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:RIVER BLUFF OF CAHOKIA NURSING & REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KENYA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-337-9823
Mailing Address - Street 1:3354 JEROME LN
Mailing Address - Street 2:
Mailing Address - City:CAHOKIA
Mailing Address - State:IL
Mailing Address - Zip Code:62206-2604
Mailing Address - Country:US
Mailing Address - Phone:618-337-9823
Mailing Address - Fax:618-332-1811
Practice Address - Street 1:3354 JEROME LN
Practice Address - Street 2:
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-2604
Practice Address - Country:US
Practice Address - Phone:618-337-9823
Practice Address - Fax:618-332-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00450053140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL145613Medicare ID - Type Unspecified