MEDICARE: RIVERSIDE RECOVERY RESOURCES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	330009PN	CA

General Provider Information

NPI Number	:	1023343167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE RECOVERY RESOURCES

Provider Business Mailing Address
First Line	:	PO BOX 549
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92531-0549
Country	:	US
Telephone Number	:	951-294-5882
Fax Number	:	951-294-5806

Provider Business Practice Location Address
First Line	:	2055 N PERRIS BLVD STE G
Second Line	:
City	:	PERRIS
State	:	CA
Zip	:	92571-2509
Country	:	US
Telephone Number	:	951-940-6061
Fax Number	:	951-674-5227

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	R KEITH SIMPSON
Credential	:	DO DPH
Telephone Number	:	951-294-5882

Provider Enumeration Date	:	10/07/2009
Last Update Date	:	08/02/2012

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