MEDICARE: RIVERSIDE FFK LLC

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	253Z00000X	In Home Supportive Care Agency
2	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9385374	OTHER	ME	SECRETARY OF STATES

General Provider Information

NPI Number	:	1679299093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE FFK LLC

Provider Business Mailing Address
First Line	:	117 SUNSET AVE APT 1
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-6156
Country	:	US
Telephone Number	:	207-233-2274
Fax Number	:

Provider Business Practice Location Address
First Line	:	53 TREMONT ST
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-6131
Country	:	US
Telephone Number	:	207-233-2274
Fax Number	:

Authorized Official
Title or Position	:	PARTNER 1
Name	:	OLANREWAJU FASHINA
Credential	:
Telephone Number	:	207-233-2274

Provider Enumeration Date	:	10/17/2022
Last Update Date	:	10/17/2022

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Directions to “RIVERSIDE FFK LLC ” Practice Location

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