Provider Demographics
NPI:1649600156
Name:RIVERTOWN ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:RIVERTOWN ASSISTED LIVING LLC
Other - Org Name:N/A
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARSHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLOMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-447-1720
Mailing Address - Street 1:16354 SW CHIPOLA RD
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-3943
Mailing Address - Country:US
Mailing Address - Phone:850-447-1720
Mailing Address - Fax:
Practice Address - Street 1:16354 SW CHIPOLA RD
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-3943
Practice Address - Country:US
Practice Address - Phone:850-447-1720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12439305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization