Provider Demographics
NPI: | 1528370855 |
---|---|
Name: | RIVERSIDE PROFESSIONAL HEALTH SERVICES, LLC |
Entity Type: | Organization |
Organization Name: | RIVERSIDE PROFESSIONAL HEALTH SERVICES, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER/DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MARCOS |
Authorized Official - Middle Name: | A |
Authorized Official - Last Name: | BEKUTO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 612-964-1735 |
Mailing Address - Street 1: | 1929 S 5TH ST STE 200 |
Mailing Address - Street 2: | |
Mailing Address - City: | MINNEAPOLIS |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55454-1274 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 612-964-1735 |
Mailing Address - Fax: | 612-359-9918 |
Practice Address - Street 1: | 1929 S 5TH ST STE 200 |
Practice Address - Street 2: | |
Practice Address - City: | MINNEAPOLIS |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55454-1274 |
Practice Address - Country: | US |
Practice Address - Phone: | 612-964-1735 |
Practice Address - Fax: | 612-359-9918 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-07-01 |
Last Update Date: | 2010-07-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 1592978 | 251E00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251E00000X | Agencies | Home Health |