Provider Demographics
NPI:1972504835
Name:RIVER VALLEY NURSING HOME, INC
Entity Type:Organization
Organization Name:RIVER VALLEY NURSING HOME, INC
Other - Org Name:GREENWAY MANOR & GREENWAY TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FACILITY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-588-0513
Mailing Address - Street 1:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:SPRING GREEN
Mailing Address - State:WI
Mailing Address - Zip Code:53588-0759
Mailing Address - Country:US
Mailing Address - Phone:608-588-2586
Mailing Address - Fax:608-588-7410
Practice Address - Street 1:501 S WINSTED ST
Practice Address - Street 2:
Practice Address - City:SPRING GREEN
Practice Address - State:WI
Practice Address - Zip Code:53588-9435
Practice Address - Country:US
Practice Address - Phone:608-588-2586
Practice Address - Fax:608-588-7410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1928310400000X
WI2470314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20144800Medicaid
WI20144800Medicaid