Provider Demographics
NPI:1801220223
Name:RIVERSIDE COMMUNITY CARE
Entity Type:Organization
Organization Name:RIVERSIDE COMMUNITY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPEUTIC MENTOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSTGARTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-834-9589
Mailing Address - Street 1:20 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:237 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-3036
Practice Address - Country:US
Practice Address - Phone:781-433-0672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health