Healthcare Provider Details

I. General information

NPI: 1508059007
Provider Name (Legal Business Name): RIVERSIDE NEUROLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7172 MAGNOLIA AVE
RIVERSIDE CA
92504-3804
US

IV. Provider business mailing address

7172 MAGNOLIA AVE
RIVERSIDE CA
92504-3804
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-2224
  • Fax: 951-788-5190
Mailing address:
  • Phone: 951-788-2224
  • Fax: 951-788-5190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA44002
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. WASEEM N IBRAHIM
Title or Position: M.D.
Credential: M.D.
Phone: 951-788-2224