Provider Demographics
NPI:1083889893
Name:RIVERSIDE HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:RIVERSIDE HEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:R
Authorized Official - Last Name:STUBBLEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:CNM/ARNP
Authorized Official - Phone:509-421-5077
Mailing Address - Street 1:819 N MILLER ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-6604
Mailing Address - Country:US
Mailing Address - Phone:509-888-1924
Mailing Address - Fax:509-888-2238
Practice Address - Street 1:819 N MILLER ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-6604
Practice Address - Country:US
Practice Address - Phone:509-888-1924
Practice Address - Fax:509-888-2238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA363LW0102X, 363LX0001X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9656919Medicaid
7532701OtherAETNA
WA4322STOtherREGENCE
WA4322STOtherASURIS NW HEALTH
WA4444890OtherCIGNA