Provider Demographics
NPI:1558830844
Name:RIVERSIDE VILLAGE
Entity Type:Organization
Organization Name:RIVERSIDE VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-417-7351
Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-0897
Mailing Address - Country:US
Mailing Address - Phone:910-417-7351
Mailing Address - Fax:
Practice Address - Street 1:8 ELLA LN
Practice Address - Street 2:
Practice Address - City:ALEXANDER
Practice Address - State:NC
Practice Address - Zip Code:28701-5509
Practice Address - Country:US
Practice Address - Phone:910-417-7351
Practice Address - Fax:828-738-2283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility