Provider Demographics
NPI:1821469602
Name:RIVERSIDE FAMILY CLINIC, INC
Entity Type:Organization
Organization Name:RIVERSIDE FAMILY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:812-291-5993
Mailing Address - Street 1:PO BOX 436
Mailing Address - Street 2:328 N 2ND ST, SUITE 102
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591
Mailing Address - Country:US
Mailing Address - Phone:812-291-5993
Mailing Address - Fax:812-316-1117
Practice Address - Street 1:328 N 2ND ST, SUITE 102
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591
Practice Address - Country:US
Practice Address - Phone:812-291-5993
Practice Address - Fax:812-316-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28140893A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty