=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417620071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERBEND HEALTHCARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2021
-----------------------------------------------------
Last Update Date | 01/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2011 HWY 61 N
-----------------------------------------------------
City | VICKSBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-456-2277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 29841
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-2050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-456-2277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MANIVANH A PRUDHOMME
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 601-456-2277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------