Provider Demographics
NPI:1326183237
Name:RIVERBIRCH RESIDENCE LLC
Entity Type:Organization
Organization Name:RIVERBIRCH RESIDENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-844-3451
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:PLANTERSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38862-0159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2554 MAIN ST
Practice Address - Street 2:
Practice Address - City:PLANTERSVILLE
Practice Address - State:MS
Practice Address - Zip Code:38862-7908
Practice Address - Country:US
Practice Address - Phone:662-844-3451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS839310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility