Healthcare Provider Details

I. General information

NPI: 1255172755
Provider Name (Legal Business Name): NAMG RIVERSIDE ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4334 CENTRAL AVE
RIVERSIDE CA
92506-2918
US

IV. Provider business mailing address

PO BOX 411825
BOSTON MA
02241-1825
US

V. Phone/Fax

Practice location:
  • Phone: 951-248-1291
  • Fax:
Mailing address:
  • Phone: 610-644-8900
  • Fax: 484-924-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GREGG MILLER
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 717-515-4048