Provider Demographics
NPI:1083819254
Name:RIVERLAKES WELLNESS MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:RIVERLAKES WELLNESS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HIXSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-369-1305
Mailing Address - Street 1:3900 COFFEE RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93308-5049
Mailing Address - Country:US
Mailing Address - Phone:661-588-5808
Mailing Address - Fax:805-369-1309
Practice Address - Street 1:3900 COFFEE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-5049
Practice Address - Country:US
Practice Address - Phone:661-588-5808
Practice Address - Fax:805-369-1309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherHEALTH NET
CA=========OtherPACIFICARE
CA=========OtherUNITED HEALTH CARE
CA=========OtherAETNA
CA=========OtherBLUE CROSS