Provider Demographics
NPI:1417620071
Name:RIVERBEND HEALTHCARE PLLC
Entity Type:Organization
Organization Name:RIVERBEND HEALTHCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MANIVANH
Authorized Official - Middle Name:A
Authorized Official - Last Name:PRUDHOMME
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-456-2277
Mailing Address - Street 1:PO BOX 29841
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2050
Mailing Address - Country:US
Mailing Address - Phone:601-456-2277
Mailing Address - Fax:
Practice Address - Street 1:2011 HWY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183
Practice Address - Country:US
Practice Address - Phone:601-456-2277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-29
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty