Provider Demographics
NPI:1912299660
Name:RIVER LODGE ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:RIVER LODGE ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:PARKER
Authorized Official - Last Name:HIGHTOWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-471-9797
Mailing Address - Street 1:217 LAKEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-8120
Mailing Address - Country:US
Mailing Address - Phone:479-471-9797
Mailing Address - Fax:479-471-7559
Practice Address - Street 1:117 RIVERLODGE DRIVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-607-0902
Practice Address - Fax:870-607-0905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR049310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185308794Medicaid