Basic Information
| Provider Information | |||||||||
| NPI: | 1396895496 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE RECOVERY CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LAKESIDE RECOVERY CENTERS OF SPOKANE, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3710 N MONROE ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992052850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093285234 | ||||||||
| FaxNumber: | 5093282358 | ||||||||
| Practice Location | |||||||||
| Address1: | 3710 N MONROE ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992052850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093285234 | ||||||||
| FaxNumber: | 5093282358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VICKERS | ||||||||
| AuthorizedOfficialFirstName: | MISTY | ||||||||
| AuthorizedOfficialMiddleName: | ARLENE SUSAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5093285234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 251S00000X | 32035100 | WA | Y | Agencies | Community/Behavioral Health |
No ID Information.