Provider Demographics
NPI:1447537758
Name:RIVERSIDE RETIREMENT SERVICE, INC
Entity type:Organization
Organization Name:RIVERSIDE RETIREMENT SERVICE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP COMMUNITY BASED SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNORS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-875-2050
Mailing Address - Street 1:1020 OLD DENBIGH BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-2017
Mailing Address - Country:US
Mailing Address - Phone:757-875-2050
Mailing Address - Fax:757-875-2070
Practice Address - Street 1:319 BROWN ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4247
Practice Address - Country:US
Practice Address - Phone:757-369-5137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERSIDE HEALTHCARE ASSOCIATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
H8655OtherMEDICARE CONTRACT NUMBER