Provider Demographics
NPI:1205123965
Name:RIVERSIDE HOME CARE, LLC
Entity type:Organization
Organization Name:RIVERSIDE HOME CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-390-7308
Mailing Address - Street 1:630 ROOSEVELT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3621
Mailing Address - Country:US
Mailing Address - Phone:949-390-7308
Mailing Address - Fax:949-390-7409
Practice Address - Street 1:11681 STERLING AVE
Practice Address - Street 2:UNIT H
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-4972
Practice Address - Country:US
Practice Address - Phone:951-375-4580
Practice Address - Fax:951-375-4581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health