1366710881 NPI number — RIVERSIDE RECOVERY RESOURCES

Table of content: (NPI 1366710881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366710881 NPI number — RIVERSIDE RECOVERY RESOURCES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE RECOVERY RESOURCES
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:
OUR HOUSE
Provider Other Organization Name Type Code:
3
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:
1366710881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE ELSINORE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92531-0549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-216-7300
Provider Business Mailing Address Fax Number:
951-674-5227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1119 W 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JACINTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92582-3856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-216-7300
Provider Business Practice Location Address Fax Number:
951-674-5227
Provider Enumeration Date:
12/12/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TRUAX
Authorized Official First Name:
BERNARD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
951-216-7300

Provider Taxonomy Codes

  • Taxonomy code: 3245S0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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