Healthcare Provider Details

I. General information

NPI: 1962428532
Provider Name (Legal Business Name): RIVERSIDE PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 ENTERPRISE PARKWAY SUITE 1200
HAMPTON VA
23666
US

IV. Provider business mailing address

850 ENTERPRISE PARKWAY SUITE 1200
HAMPTON VA
23666
US

V. Phone/Fax

Practice location:
  • Phone: 757-838-4500
  • Fax: 757-896-4732
Mailing address:
  • Phone: 757-838-4500
  • Fax: 757-896-4732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES LESNICK
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 757-594-4006