Healthcare Provider Details

I. General information

NPI: 1396895496
Provider Name (Legal Business Name): RIVERSIDE RECOVERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 N MONROE ST
SPOKANE WA
99205-2850
US

IV. Provider business mailing address

3710 N MONROE ST
SPOKANE WA
99205-2850
US

V. Phone/Fax

Practice location:
  • Phone: 509-328-5234
  • Fax: 509-328-2358
Mailing address:
  • Phone: 509-328-5234
  • Fax: 509-328-2358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number32035100
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISTY ARLENE SUSAN VICKERS
Title or Position: OFFICE MANAGER
Credential:
Phone: 509-328-5234