Provider Demographics
NPI:1578162517
Name:RIVERSIDE HEALTH SOURCE LLC
Entity Type:Organization
Organization Name:RIVERSIDE HEALTH SOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:W
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:757-875-7545
Mailing Address - Street 1:608 DENBIGH BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-4487
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:659 HOSPITAL RD STE 103A
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-7000
Practice Address - Country:US
Practice Address - Phone:804-443-6276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health