Healthcare Provider Details

I. General information

NPI: 1083630545
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: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 KINGS WAY SUITE 1300
WILLIAMSBURG VA
23185-2505
US

IV. Provider business mailing address

120 KINGS WAY SUITE 1300
WILLIAMSBURG VA
23185-2505
US

V. Phone/Fax

Practice location:
  • Phone: 757-345-1001
  • Fax: 757-345-3102
Mailing address:
  • Phone: 757-345-3001
  • Fax: 757-345-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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