1528370855 NPI number — RIVERSIDE PROFESSIONAL HEALTH SERVICES, LLC

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 1528370855 NPI number — RIVERSIDE PROFESSIONAL HEALTH SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE PROFESSIONAL HEALTH SERVICES, 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:
1528370855
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1929 S 5TH ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55454-1274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-964-1735
Provider Business Mailing Address Fax Number:
612-359-9918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1929 S 5TH ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55454-1274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-964-1735
Provider Business Practice Location Address Fax Number:
612-359-9918
Provider Enumeration Date:
07/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BEKUTO
Authorized Official First Name:
MARCOS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
612-964-1735

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  1592978 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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