Healthcare Provider Details

I. General information

NPI: 1629336235
Provider Name (Legal Business Name): RIVERSIDE CITY GYM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 UNIVERSITY AVE
RIVERSIDE CA
92501-3326
US

IV. Provider business mailing address

3485 UNIVERSITY AVE
RIVERSIDE CA
92501-3326
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-6115
  • Fax: 951-788-6115
Mailing address:
  • Phone: 951-788-6115
  • Fax: 951-788-6115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name: PENNY WILSON
Title or Position: MANAGER
Credential:
Phone: 951-788-6115