Healthcare Provider Details

I. General information

NPI: 1346390796
Provider Name (Legal Business Name): RIVERSIDE SERVICE GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

461 RIVER PKWY
IDAHO FALLS ID
83402-3314
US

IV. Provider business mailing address

3925 N AMMON RD
IDAHO FALLS ID
83401-1313
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-4517
  • Fax: 208-528-9501
Mailing address:
  • Phone: 208-521-6573
  • Fax: 208-528-9501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number805608500
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number807612600
License Number StateID

VIII. Authorized Official

Name: MRS. KATHLEEN ANN HANSEN
Title or Position: PRESIDENT CEO
Credential:
Phone: 208-521-6573