Provider Demographics
NPI:1851652416
Name:RIVERSIDE FAMILY HEALTH LLC
Entity Type:Organization
Organization Name:RIVERSIDE FAMILY HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:LANDRUM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:256-355-7665
Mailing Address - Street 1:1501 7TH ST SE STE A
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-3375
Mailing Address - Country:US
Mailing Address - Phone:256-355-7665
Mailing Address - Fax:256-686-3241
Practice Address - Street 1:1501 7TH ST SE STE A
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3375
Practice Address - Country:US
Practice Address - Phone:256-355-7665
Practice Address - Fax:256-686-3241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-093034363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL138745Medicaid
AL12404856OtherCAQH
AL140473Medicaid
AL51126863OtherBCBS