Provider Demographics
NPI:1649233545
Name:RIVERSIDE FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:RIVERSIDE FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUTENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-694-7887
Mailing Address - Street 1:PO BOX 51589
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33994-1589
Mailing Address - Country:US
Mailing Address - Phone:239-694-7887
Mailing Address - Fax:239-694-8941
Practice Address - Street 1:14651 PALM BEACH BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-2331
Practice Address - Country:US
Practice Address - Phone:239-694-7887
Practice Address - Fax:239-694-8941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center