Provider Demographics
NPI:1952320111
Name:RIVERSIDE ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:RIVERSIDE ASSISTED LIVING LLC
Other - Org Name:RIVERSIDE PLACE ASSISTED LIVING COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-650-7086
Mailing Address - Street 1:1151 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-6400
Mailing Address - Country:US
Mailing Address - Phone:229-248-1116
Mailing Address - Fax:229-248-4115
Practice Address - Street 1:1151 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-6400
Practice Address - Country:US
Practice Address - Phone:229-248-1116
Practice Address - Fax:229-248-4115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home