1508828963 NPI number — RIVERSIDE EYE SPECIALISTS MEDICAL GROUP INC.

Table of content: (NPI 1508828963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508828963 NPI number — RIVERSIDE EYE SPECIALISTS MEDICAL GROUP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE EYE SPECIALISTS MEDICAL GROUP 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:
1508828963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2013
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 100
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:
951-686-4911
Provider Business Mailing Address Fax Number:
951-686-9409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4605 BROCKTON AVE
Provider Second Line Business Practice Location Address:
SUITE 100
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:
951-686-4911
Provider Business Practice Location Address Fax Number:
951-686-9409
Provider Enumeration Date:
04/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLENDRANGE
Authorized Official First Name:
RAY
Authorized Official Middle Name:
ROGERS
Authorized Official Title or Position:
SECRETARY/OWNER
Authorized Official Telephone Number:
951-686-4911

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CD8734 . This is a "PALMETTO, GBA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0079980 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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