Provider Demographics
NPI:1871651422
Name:PHIL WAGGONER
Entity Type:Organization
Organization Name:PHIL WAGGONER
Other - Org Name:RIVERSIDE RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFC MANAGER OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-746-4097
Mailing Address - Street 1:1720 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-746-4097
Mailing Address - Fax:208-746-2294
Practice Address - Street 1:1720 18TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4047
Practice Address - Country:US
Practice Address - Phone:208-746-4097
Practice Address - Fax:208-746-2294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID138101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty