Provider Demographics
NPI:1225108830
Name:RIVERSIDE OPTICAL INC
Entity Type:Organization
Organization Name:RIVERSIDE OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNES
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-556-4440
Mailing Address - Street 1:535 JACK WARNER PKWY NE STE B2
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-5715
Mailing Address - Country:US
Mailing Address - Phone:205-554-0107
Mailing Address - Fax:205-554-0198
Practice Address - Street 1:535 JACK WARNER PKWY NE STE B2
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5715
Practice Address - Country:US
Practice Address - Phone:205-554-0107
Practice Address - Fax:205-554-0198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0715100001Medicare NSC