Provider Demographics
NPI:1417326968
Name:RIVERSIDE ORTHOPEDIC CLINIC
Entity Type:Organization
Organization Name:RIVERSIDE ORTHOPEDIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-452-3111
Mailing Address - Street 1:910 NW 16TH ST
Mailing Address - Street 2:#205
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2265
Mailing Address - Country:US
Mailing Address - Phone:208-452-3111
Mailing Address - Fax:208-452-3666
Practice Address - Street 1:910 NW 16TH ST
Practice Address - Street 2:#205
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2265
Practice Address - Country:US
Practice Address - Phone:208-452-3111
Practice Address - Fax:208-452-3666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10556207X00000X
IDM-10864207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty