=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619741063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERSIDE CARE CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2023
-----------------------------------------------------
Last Update Date | 11/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 402 N RIVERSIDE DR
-----------------------------------------------------
City | NEW SMYRNA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32168-6740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-423-1120
-----------------------------------------------------
Fax | 386-957-3770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 402 N RIVERSIDE DR
-----------------------------------------------------
City | NEW SMYRNA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32168-6740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-423-1120
-----------------------------------------------------
Fax | 386-957-3770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | SANDRA VENORD DORVAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-947-6368
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------