Provider Demographics
NPI:1720027105
Name:RIVERSIDE REHABILITATION AGENCY, INC.
Entity Type:Organization
Organization Name:RIVERSIDE REHABILITATION AGENCY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-936-2021
Mailing Address - Street 1:6835 S FIELDGATE CT
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-5452
Mailing Address - Country:US
Mailing Address - Phone:225-936-2021
Mailing Address - Fax:
Practice Address - Street 1:8680 BLUEBONNET BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-7825
Practice Address - Country:US
Practice Address - Phone:225-936-2021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1566250Medicaid
LA1566250Medicaid