Provider Demographics
NPI:1841296340
Name:RIVERSIDE PROSTHETIC, INC.
Entity type:Organization
Organization Name:RIVERSIDE PROSTHETIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGULATORY COMPLIANCE ANALYST III
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-594-2709
Mailing Address - Street 1:PO BOX 650846
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5921 VOGEL RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4020
Practice Address - Country:US
Practice Address - Phone:812-479-7577
Practice Address - Fax:812-479-7595
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-21
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 335E00000X, 335E00000X
VACPO 1886222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200091110AMedicaid
1094850001Medicare ID - Type Unspecified