Basic Information
Provider Information | |||||||||
NPI: | 1780782557 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RIVERSIDE MEDICAL CLINIC INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3660 ARLINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | RIVERSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 92506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516836370 | ||||||||
FaxNumber: | 9517825135 | ||||||||
Practice Location | |||||||||
Address1: | 6405 DAY STREET | ||||||||
Address2: |   | ||||||||
City: | RIVERSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 92506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516975555 | ||||||||
FaxNumber: | 9517825135 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ATWOOD | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR BUSINESS SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9517825136 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   | 207KA0200X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | 207LP2900X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207N00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   | 207Q00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207V00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207X00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207Y00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |   | 208000000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 208200000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |   | 208600000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   | 213E00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   | 231H00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |   | 111N00000X |   | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   |
No ID Information.