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General NPI Number Information
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NPI Number | 1346390796
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Entity Type | Organization
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Legal Business Name | RIVERSIDE SERVICE GROUP INC
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 06/25/2010
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Provider Practice Location Address
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Address Line | 461 RIVER PKWY
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3314
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Country | US
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Telephone | 208-542-4517
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Fax | 208-528-9501
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Provider Business Mailing Address
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Address Line | 3925 N AMMON RD
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City | IDAHO FALLS
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State | ID
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Zip | 83401-1313
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Country | US
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Telephone | 208-521-6573
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Fax | 208-528-9501
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Authorized Official
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Title or Position | PRESIDENT CEO
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Name | MRS. KATHLEEN ANN HANSEN
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Credential |
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Telephone | 208-521-6573
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | 807612600
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | 805608500
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License Number State | ID
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