Provider Demographics
NPI:1346390796
Name:RIVERSIDE SERVICE GROUP INC
Entity Type:Organization
Organization Name:RIVERSIDE SERVICE GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-521-6573
Mailing Address - Street 1:3925 N AMMON RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-1313
Mailing Address - Country:US
Mailing Address - Phone:208-521-6573
Mailing Address - Fax:208-528-9501
Practice Address - Street 1:461 RIVER PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3314
Practice Address - Country:US
Practice Address - Phone:208-542-4517
Practice Address - Fax:208-528-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID807612600171M00000X
ID805608500251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805608500Medicaid
ID807612600Medicaid