Healthcare Provider Details

I. General information

NPI: 1356059877
Provider Name (Legal Business Name): RIVERSIDE ADDICTION SPECIALISTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 BROCKTON AVE STE 100
RIVERSIDE CA
92506-0107
US

IV. Provider business mailing address

4605 BROCKTON AVE STE 100
RIVERSIDE CA
92506-0107
US

V. Phone/Fax

Practice location:
  • Phone: 951-830-5874
  • Fax: 951-686-9409
Mailing address:
  • Phone: 951-830-5874
  • Fax: 951-686-9409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RAY GLENDRANGE
Title or Position: PRESIDENT
Credential: MD
Phone: 951-830-5874