Provider Demographics
NPI:1477919132
Name:RIVER VALLEY SUPPORTIVE LIVING LLC
Entity Type:Organization
Organization Name:RIVER VALLEY SUPPORTIVE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEBZENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-452-6804
Mailing Address - Street 1:PO BOX 597665
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-7665
Mailing Address - Country:US
Mailing Address - Phone:847-452-6804
Mailing Address - Fax:773-305-2998
Practice Address - Street 1:1975 E COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2781
Practice Address - Country:US
Practice Address - Phone:815-936-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility