Provider Demographics
NPI:1023372067
Name:RIVERSIDE CHIROPRACTIC WELLNESS CENTERS, INC
Entity Type:Organization
Organization Name:RIVERSIDE CHIROPRACTIC WELLNESS CENTERS, INC
Other - Org Name:RIVERSIDE CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:POURSHADI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:781-395-0003
Mailing Address - Street 1:181 TAFT RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01887-2820
Mailing Address - Country:US
Mailing Address - Phone:781-395-0003
Mailing Address - Fax:781-395-2223
Practice Address - Street 1:65 RIVERSIDE AVE STE C
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4653
Practice Address - Country:US
Practice Address - Phone:781-395-0003
Practice Address - Fax:781-395-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2413261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1697218Medicaid
MAPOY45476Medicare UPIN