Healthcare Provider Details

I. General information

NPI: 1447537758
Provider Name (Legal Business Name): RIVERSIDE RETIREMENT SERVICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 BROWN ST
PETERSBURG VA
23803-4247
US

IV. Provider business mailing address

1020 OLD DENBIGH BLVD
NEWPORT NEWS VA
23602-2017
US

V. Phone/Fax

Practice location:
  • Phone: 757-369-5137
  • Fax:
Mailing address:
  • Phone: 757-875-2050
  • Fax: 757-875-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: CRAIG CONNORS
Title or Position: VP COMMUNITY BASED SERVICES
Credential:
Phone: 757-875-2050