Provider Demographics
NPI:1295198497
Name:THE RIVER SOURCE OUTPATIENT PEORIA
Entity Type:Organization
Organization Name:THE RIVER SOURCE OUTPATIENT PEORIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNT MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-413-9860
Mailing Address - Street 1:2432 W PEORIA AVE
Mailing Address - Street 2:SUITE 1227
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4737
Mailing Address - Country:US
Mailing Address - Phone:623-277-8385
Mailing Address - Fax:
Practice Address - Street 1:2432 W PEORIA AVE
Practice Address - Street 2:SUITE 1227
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4726
Practice Address - Country:US
Practice Address - Phone:623-277-8385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCSLG7631261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder