Healthcare Provider Details

I. General information

NPI: 1386980555
Provider Name (Legal Business Name): RIVERSIDE COUNTY DEPT MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 ATLANTA AVE STE G1
RIVERSIDE CA
92507-7417
US

IV. Provider business mailing address

1777 ATLANTA AVE STE G1
RIVERSIDE CA
92507-7417
US

V. Phone/Fax

Practice location:
  • Phone: 951-778-3504
  • Fax:
Mailing address:
  • Phone: 951-778-3504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberHO502091228
License Number StateCA

VIII. Authorized Official

Name: NATHANIEL TOLLEFSON
Title or Position: SUPERVISOR
Credential: CADC 11
Phone: 951-778-3504