Provider Demographics
NPI:1104818459
Name:RIVERSIDE IMAGING LLC
Entity type:Organization
Organization Name:RIVERSIDE IMAGING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-344-8203
Mailing Address - Street 1:4000 14TH ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4083
Mailing Address - Country:US
Mailing Address - Phone:951-276-7500
Mailing Address - Fax:951-276-7543
Practice Address - Street 1:4000 14TH ST
Practice Address - Street 2:SUITE 109
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4083
Practice Address - Country:US
Practice Address - Phone:951-276-7500
Practice Address - Fax:951-276-7543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIDTF00710Medicaid
CAP00380860OtherRR MEDICARE
CAIDTF00710Medicaid