Healthcare Provider Details

I. General information

NPI: 1689615528
Provider Name (Legal Business Name): RIVERSIDE COMMUNITY SUPPORTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MITCHELL ST N
AHOSKIE NC
27910-3029
US

IV. Provider business mailing address

PO BOX 426
POWELLSVILLE NC
27967-0426
US

V. Phone/Fax

Practice location:
  • Phone: 252-862-4111
  • Fax: 252-862-4211
Mailing address:
  • Phone: 252-862-4111
  • Fax: 252-862-4211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTWANE HECKSTALL
Title or Position: CEO PRESIDENT
Credential: BA QP
Phone: 252-862-4111