Provider Demographics
NPI:1376601997
Name:RIVERSIDE SENIOR LIVING
Entity Type:Organization
Organization Name:RIVERSIDE SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:AYERS
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:641-228-2800
Mailing Address - Street 1:209 PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLES CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50616
Mailing Address - Country:US
Mailing Address - Phone:641-228-2800
Mailing Address - Fax:641-228-3886
Practice Address - Street 1:209 PARK DR
Practice Address - Street 2:
Practice Address - City:CHARLES CITY
Practice Address - State:IA
Practice Address - Zip Code:50616-1619
Practice Address - Country:US
Practice Address - Phone:641-228-2800
Practice Address - Fax:641-228-3886
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHAUTAUQUA GUEST HOMES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-05
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0194310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0473231Medicaid