Provider Demographics
NPI:1407865884
Name:LIBERTY NURSING CENTER OF RIVERSIDE, LLC
Entity Type:Organization
Organization Name:LIBERTY NURSING CENTER OF RIVERSIDE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK-KUREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-296-1550
Mailing Address - Street 1:7445 LIBERTY WOODS LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3911
Mailing Address - Country:US
Mailing Address - Phone:937-296-1550
Mailing Address - Fax:937-296-1540
Practice Address - Street 1:315 LILIENTHAL ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45204-1170
Practice Address - Country:US
Practice Address - Phone:513-471-8667
Practice Address - Fax:513-557-3629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNH-014659-NH3140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2553928Medicaid
OH365925Medicare Oscar/Certification