Healthcare Provider Details

I. General information

NPI: 1124206941
Provider Name (Legal Business Name): RIVERSIDE IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 14TH ST SUITE 109
RIVERSIDE CA
92501-4083
US

IV. Provider business mailing address

4000 14TH ST SUITE 109
RIVERSIDE CA
92501-4083
US

V. Phone/Fax

Practice location:
  • Phone: 951-276-7500
  • Fax: 951-276-7543
Mailing address:
  • Phone: 951-276-7500
  • Fax: 951-276-7543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: LAVELLE R HARDIN
Title or Position: CREDENTIALING ANAYLEST
Credential:
Phone: 615-344-8203