Healthcare Provider Details

I. General information

NPI: 1255789855
Provider Name (Legal Business Name): RIVERSIDE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 14TH ST
RIVERSIDE CA
92501-3815
US

IV. Provider business mailing address

3625 14TH ST
RIVERSIDE CA
92501-3815
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-1540
  • Fax: 951-955-1610
Mailing address:
  • Phone: 951-955-1540
  • Fax: 951-955-1610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberLMFT48591
License Number StateCA

VIII. Authorized Official

Name: MRS. CLAUDIA SMITH
Title or Position: ADMINISTRATOR
Credential: LCSW
Phone: 951-955-1540