1316010499 NPI number — RIVERSIDE PLASTIC SURGERY ASSOCIATES INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316010499 NPI number — RIVERSIDE PLASTIC SURGERY ASSOCIATES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE PLASTIC SURGERY ASSOCIATES INC.
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:
1316010499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4605 BROCKTON AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92506-0106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-781-4339
Provider Business Mailing Address Fax Number:
951-274-0985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4605 BROCKTON AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92506-0106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-781-4339
Provider Business Practice Location Address Fax Number:
951-274-0985
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHILDERS
Authorized Official First Name:
BEN
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT CFO
Authorized Official Telephone Number:
951-781-4339

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G76953 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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