1083889893 NPI number — RIVERSIDE HEALTH CENTER, LLC

Table of content: (NPI 1083889893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083889893 NPI number — RIVERSIDE HEALTH CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE HEALTH CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083889893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
819 N MILLER ST
Provider Second Line Business Mailing Address:
SUITE 1B
Provider Business Mailing Address City Name:
WENATCHEE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98801-6604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-888-1924
Provider Business Mailing Address Fax Number:
509-888-2238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
819 N MILLER ST
Provider Second Line Business Practice Location Address:
SUITE 1B
Provider Business Practice Location Address City Name:
WENATCHEE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98801-6604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-888-1924
Provider Business Practice Location Address Fax Number:
509-888-2238
Provider Enumeration Date:
04/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
STUBBLEFIELD
Authorized Official First Name:
STACY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
509-421-5077

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LX0001X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9656919 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7532701 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4322ST . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4322ST . This is a "ASURIS NW HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4444890 . This is a "CIGNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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