Healthcare Provider Details

I. General information

NPI: 1811091374
Provider Name (Legal Business Name): RIVERSIDE EYE, EAR, NOSE,THROAT INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BROCKTON AVE L05
RIVERSIDE CA
92501-4090
US

IV. Provider business mailing address

4500 BROCKTON AVE L05
RIVERSIDE CA
92501-4090
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-2788
  • Fax:
Mailing address:
  • Phone: 951-788-2788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number250000356
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN J. ALLAVIE
Title or Position: PRESIDENT
Credential: MD
Phone: 951-686-4911