Provider Demographics
NPI:1114288586
Name:RIVERSIDE LIFE SERVICES, INC
Entity Type:Organization
Organization Name:RIVERSIDE LIFE SERVICES, INC
Other - Org Name:RIVERSIDE LIFE SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MINAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:951-340-1002
Mailing Address - Street 1:3727 MCCRAY ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2928
Mailing Address - Country:US
Mailing Address - Phone:951-784-2422
Mailing Address - Fax:951-276-2907
Practice Address - Street 1:3727 MCCRAY ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2928
Practice Address - Country:US
Practice Address - Phone:951-784-2422
Practice Address - Fax:951-276-2907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health