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General NPI Number Information
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NPI Number | 1508828963
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Entity Type | Organization
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Legal Business Name | RIVERSIDE EYE SPECIALISTS MEDICAL GROUP INC.
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Dates
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Enumeration Date | 04/03/2006
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Last Update Date | 11/26/2013
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Provider Practice Location Address
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Address Line | 4605 BROCKTON AVE SUITE 100
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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 | 951-686-4911
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Fax | 951-686-9409
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Provider Business Mailing Address
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Address Line | 4605 BROCKTON AVE SUITE 100
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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 | 951-686-4911
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Fax | 951-686-9409
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Authorized Official
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Title or Position | SECRETARY/OWNER
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Name | DR. RAY ROGERS GLENDRANGE
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Credential | M.D.
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Telephone | 951-686-4911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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