Basic Information
| Provider Information | |||||||||
| NPI: | 1649233545 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVERSIDE FAMILY PRACTICE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51589 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339941589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396947887 | ||||||||
| FaxNumber: | 2396948941 | ||||||||
| Practice Location | |||||||||
| Address1: | 14651 PALM BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339052331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396947887 | ||||||||
| FaxNumber: | 2396948941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 02/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | LAUTENBACH | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2396947887 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.