Provider Demographics
NPI:1811412539
Name:RIVER CITY COMPANIONSHIP LLC
Entity Type:Organization
Organization Name:RIVER CITY COMPANIONSHIP LLC
Other - Org Name:RIVER CITY COMPANIONSHIP L.L.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MCCALLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-241-4937
Mailing Address - Street 1:7857 DELAROCHE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-2566
Mailing Address - Country:US
Mailing Address - Phone:904-378-0561
Mailing Address - Fax:904-378-0561
Practice Address - Street 1:7857 DELAROCHE DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210
Practice Address - Country:US
Practice Address - Phone:904-378-0561
Practice Address - Fax:904-378-0561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL234691261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021062800Medicaid