Healthcare Provider Details

I. General information

NPI: 1861074767
Provider Name (Legal Business Name): RIVERSIDE LIFE ENRICHMENT CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 E BURKE RD
LYNDONVILLE VT
05851-9230
US

IV. Provider business mailing address

2104 E BURKE RD
LYNDONVILLE VT
05851-9230
US

V. Phone/Fax

Practice location:
  • Phone: 802-626-3900
  • Fax:
Mailing address:
  • Phone: 802-626-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEO H COUTU
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 802-626-3900