Provider Demographics
NPI:1174603377
Name:RIVERSIDE SENIOR LIVING CENTER
Entity type:Organization
Organization Name:RIVERSIDE SENIOR LIVING CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:SCHILTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-935-7256
Mailing Address - Street 1:1601 BUTTERFIELD TRL
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2959
Mailing Address - Country:US
Mailing Address - Phone:815-936-6500
Mailing Address - Fax:815-936-8965
Practice Address - Street 1:1601 BUTTERFIELD TRL
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2959
Practice Address - Country:US
Practice Address - Phone:815-936-6500
Practice Address - Fax:815-936-8965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0040659314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL747OtherBC/BS PROVIDER #
IL=========001Medicaid
IL=========001Medicaid