MEDICARE: RIVERSIDE CARE CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1619741063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE CARE CENTER, INC

Provider Business Mailing Address
First Line	:	402 N RIVERSIDE DR
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-6740
Country	:	US
Telephone Number	:	386-423-1120
Fax Number	:	386-957-3770

Provider Business Practice Location Address
First Line	:	402 N RIVERSIDE DR
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-6740
Country	:	US
Telephone Number	:	386-423-1120
Fax Number	:	386-957-3770

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	SANDRA VENORD DORVAL
Credential	:
Telephone Number	:	321-947-6368

Provider Enumeration Date	:	11/07/2023
Last Update Date	:	11/07/2023

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