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General NPI Number Information
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NPI Number | 1316010499
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Entity Type | Organization
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Legal Business Name | RIVERSIDE PLASTIC SURGERY ASSOCIATES INC.
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Dates
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Enumeration Date | 11/16/2006
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Last Update Date | 09/09/2009
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Provider Practice Location Address
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Address Line | 4605 BROCKTON AVE SUITE 200
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City | RIVERSIDE
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State | CA
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Zip | 92506-0106
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Country | US
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Telephone | 951-781-4339
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Fax | 951-274-0985
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Provider Business Mailing Address
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Address Line | 4605 BROCKTON AVE SUITE 200
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City | RIVERSIDE
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State | CA
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Zip | 92506-0106
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Country | US
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Telephone | 951-781-4339
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Fax | 951-274-0985
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Authorized Official
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Title or Position | PRESIDENT CFO
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Name | BEN J. CHILDERS
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Credential | M.D.
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Telephone | 951-781-4339
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G76953
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License Number State | CA
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