| Organization Name: | RIVERSIDE MEDICAL CLINIC INC |
| NPI Number: | 1508263088 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TARA S WILLIAMS (PRESIDENT) |
| Mailing Address: | 20886 Riverside Dr Grundy |
| State: | VA US |
| Postal Code: | 246149597 |
| Phone Number: | 2769357515 |
| Fax Number: | 2769354351 |
| NPI Enumeration Date: | 11/26/2014 |
| NPI Last Update Date: | 12/01/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 0024168117 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | VA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |