=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043372618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERBANK PRIMARY CARE MEDICAL CLINIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 07/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3227 STANISLAUS ST. STE 'A'
-----------------------------------------------------
City | RIVERBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-869-0131
-----------------------------------------------------
Fax | 209-869-5409
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3227 STANISLAUS ST. STE 'A'
-----------------------------------------------------
City | RIVERBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-869-0131
-----------------------------------------------------
Fax | 209-869-5409
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NAOMI REYNOLDS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 209-869-0131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | RHM53859F
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------