Healthcare Provider Details

I. General information

NPI: 1104290949
Provider Name (Legal Business Name): RIVERSIDE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 RIVERSIDE DR
FRANKLINTON LA
70438-3635
US

IV. Provider business mailing address

809 RIVERSIDE DR
FRANKLINTON LA
70438-3635
US

V. Phone/Fax

Practice location:
  • Phone: 985-795-4208
  • Fax: 985-795-4210
Mailing address:
  • Phone: 985-795-4208
  • Fax: 985-795-4210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number168
License Number StateLA

VIII. Authorized Official

Name: STACEY K MCGRAW
Title or Position: BUSINESS OFFICE DIRECTOR
Credential:
Phone: 985-795-4168