Provider Demographics
NPI:1285632877
Name:RIVER RIDGE LIVING CENTER, LLC
Entity Type:Organization
Organization Name:RIVER RIDGE LIVING CENTER, LLC
Other - Org Name:THE PROVIDERS, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:E
Authorized Official - Last Name:REYNICKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-843-3503
Mailing Address - Street 1:100 SANDY DR
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-8191
Mailing Address - Country:US
Mailing Address - Phone:518-843-3503
Mailing Address - Fax:518-843-3537
Practice Address - Street 1:100 SANDY DR
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-8191
Practice Address - Country:US
Practice Address - Phone:518-843-3503
Practice Address - Fax:518-843-3537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0460026314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00308787Medicaid
NY335422Medicare ID - Type Unspecified