Basic Information
| Provider Information | |||||||||
| NPI: | 1194978585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE CARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 220 | ||||||||
| Address2: | 100 EAGLEVILLE RD | ||||||||
| City: | EAGLEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194080220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106357445 | ||||||||
| FaxNumber: | 6105392625 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180185947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108680435 | ||||||||
| FaxNumber: | 6108685552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2008 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | ROTELLA | ||||||||
| AuthorizedOfficialFirstName: | ADRIENNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6106357445 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 214720 | PA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1007578550032 | 05 | PA | MEDICAID |