Provider Demographics
NPI:1669887352
Name:DIVERSICARE OF RIVERSIDE, LLC
Entity type:Organization
Organization Name:DIVERSICARE OF RIVERSIDE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEISHAAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:1616 WEISENBORN RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-2527
Mailing Address - Country:US
Mailing Address - Phone:816-232-9874
Mailing Address - Fax:816-364-4283
Practice Address - Street 1:1616 WEISENBORN RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-2527
Practice Address - Country:US
Practice Address - Phone:816-232-9874
Practice Address - Fax:816-364-4283
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-22
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042402310400000X
MO042401314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1669887352Medicaid
MO265827Medicare Oscar/Certification