Provider Demographics
NPI:1497972624
Name:RIVERSIDE NURSING AND REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:RIVERSIDE NURSING AND REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NORBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-662-4955
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-662-4955
Mailing Address - Fax:716-662-2529
Practice Address - Street 1:4700 NW CLIFFVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:MO
Practice Address - Zip Code:64150-1237
Practice Address - Country:US
Practice Address - Phone:816-741-5105
Practice Address - Fax:816-741-5281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102691607Medicaid