Provider Demographics
NPI:1952475485
Name:RIVERSIDE NURSING - CENTRALIA LLC
Entity Type:Organization
Organization Name:RIVERSIDE NURSING - CENTRALIA LLC
Other - Org Name:RIVERSIDE NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOV
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-678-4426
Mailing Address - Street 1:1305 ALEXANDER ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-1305
Mailing Address - Country:US
Mailing Address - Phone:360-736-2823
Mailing Address - Fax:360-736-1821
Practice Address - Street 1:1305 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1305
Practice Address - Country:US
Practice Address - Phone:360-736-2823
Practice Address - Fax:360-736-1821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4197000Medicaid
WA505358Medicare Oscar/Certification