Provider Demographics
NPI:1033970454
Name:RIVERS EDGE BOUTIQUE MEDICINE LLC
Entity Type:Organization
Organization Name:RIVERS EDGE BOUTIQUE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:727-342-4955
Mailing Address - Street 1:5647 MAIN ST STE 1&2
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-2641
Mailing Address - Country:US
Mailing Address - Phone:727-831-8376
Mailing Address - Fax:
Practice Address - Street 1:5647 MAIN ST STE 1&2
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2641
Practice Address - Country:US
Practice Address - Phone:727-831-8376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty