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General NPI Number Information
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NPI Number | 1003693961
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Entity Type | Organization
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Legal Business Name | RIVERSIDE PRIMARY CARE ADULT AND GERIATRIC MEDICINE PLLLP
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Dates
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Enumeration Date | 09/13/2023
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Last Update Date | 09/13/2023
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Provider Practice Location Address
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Address Line | 1673 W SHORELINE DR STE 100
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City | BOISE
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State | ID
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Zip | 83702-6749
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Country | US
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Telephone | 208-593-3054
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Fax |
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Provider Business Mailing Address
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Address Line | 1673 W SHORELINE DR STE 100
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City | BOISE
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State | ID
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Zip | 83702-6749
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | JESSICA LONG
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Credential | NP
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Telephone | 208-850-1940
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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