Basic Information
| Provider Information | |||||||||
| NPI: | 1568507853 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER REGION HUMAN SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 CARMICHAEL AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322072325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048996300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3901 CARMICHAEL AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322072325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048996300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | DISTEFANO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL CONSULTANT | ||||||||
| AuthorizedOfficialTelephone: | 3523173214 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | FL | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 060605700 | 05 | FL | MEDICAID |