Provider Demographics
NPI:1578659645
Name:RIVERSIDE ARTIFICIAL LIMB & BRACE CORP
Entity Type:Organization
Organization Name:RIVERSIDE ARTIFICIAL LIMB & BRACE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARTCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED ORTHOTIST
Authorized Official - Phone:951-781-3011
Mailing Address - Street 1:4013 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3440
Mailing Address - Country:US
Mailing Address - Phone:951-781-3011
Mailing Address - Fax:951-781-4751
Practice Address - Street 1:4013 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3440
Practice Address - Country:US
Practice Address - Phone:951-781-3011
Practice Address - Fax:951-781-4751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000440Medicaid
CACGP124195OtherCCS
CAGXC000440Medicaid