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
StateLicense IDTaxonomies
MN1592978251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health