=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215186267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1ST ASSIST OF RIVERSIDE MEDICAL CORPORATION, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2008
-----------------------------------------------------
Last Update Date | 09/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1855 CANYON HILL DR
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92506-5670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-720-1130
-----------------------------------------------------
Fax | 951-789-1413
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1855 CANYON HILL DR
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92506-5670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-720-1130
-----------------------------------------------------
Fax | 951-789-1413
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. KAYLEETA EVONNE ROBINSON
-----------------------------------------------------
Credential | RNFA
-----------------------------------------------------
Telephone | 909-720-1130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 376658
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------