Basic Information
Provider Information | |||||||||
NPI: | 1871902452 | ||||||||
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: | 925063912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516836370 | ||||||||
FaxNumber: | 9512486708 | ||||||||
Practice Location | |||||||||
Address1: | 19314 JESSE LN | ||||||||
Address2: | SUITE 150 | ||||||||
City: | RIVERSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 925085069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516836370 | ||||||||
FaxNumber: | 9512486708 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/07/2014 | ||||||||
LastUpdateDate: | 08/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARPENTER | ||||||||
AuthorizedOfficialFirstName: | JUDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT, COO | ||||||||
AuthorizedOfficialTelephone: | 9517823744 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | COO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.