Provider Demographics
NPI:1649567504
Name:RIVERSIDE MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:RIVERSIDE MEDICAL CENTER LLC
Other - Org Name:BLUE ROCK MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-229-2002
Mailing Address - Street 1:3152 N UNIVERSITY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4729
Mailing Address - Country:US
Mailing Address - Phone:801-229-2002
Mailing Address - Fax:801-229-1003
Practice Address - Street 1:3152 N UNIVERSITY AVE STE 100
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4729
Practice Address - Country:US
Practice Address - Phone:801-229-2002
Practice Address - Fax:801-229-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-29
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty