Provider Demographics
NPI:1598808016
Name:RIVERSIDE COMMUNITY COMMUNITY
Entity Type:Organization
Organization Name:RIVERSIDE COMMUNITY COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMERGENCY SERVICES CLINICIAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:TIA
Authorized Official - Middle Name:
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:508-612-0761
Mailing Address - Street 1:8 PRUDENTIAL RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1524
Mailing Address - Country:US
Mailing Address - Phone:508-612-0761
Mailing Address - Fax:
Practice Address - Street 1:8 PRUDENTIAL RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-1524
Practice Address - Country:US
Practice Address - Phone:508-612-0761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health