Provider Demographics
NPI:1518200773
Name:RIVERSQUARE CLINIC, LLC
Entity Type:Organization
Organization Name:RIVERSQUARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSEOK
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-944-0985
Mailing Address - Street 1:140 SYLVAN AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2514
Mailing Address - Country:US
Mailing Address - Phone:201-944-0985
Mailing Address - Fax:201-944-0912
Practice Address - Street 1:140 SYLVAN AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2514
Practice Address - Country:US
Practice Address - Phone:201-944-0985
Practice Address - Fax:201-944-0912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00088900261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center