Healthcare Provider Details

I. General information

NPI: 1659062487
Provider Name (Legal Business Name): EVERSIDE-CA IRONWORKERS-RIVERSIDE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3637 ARLINGTON AVE STE A
RIVERSIDE CA
92506-3920
US

IV. Provider business mailing address

4651 CHARLOTTE PARK DR STE 300
CHARLOTTE NC
28217-1916
US

V. Phone/Fax

Practice location:
  • Phone: 704-661-1380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL JOHNSON PATTON
Title or Position: DIRECTOR OF RISK MANAGEMENT
Credential:
Phone: 704-936-5546