Organization
RIVERSIDE SERVICE GROUP INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KATHLEEN ANN HANSEN (PRESIDENT CEO)
(208) 521-6573
Entity
Organization
Contact information
Practice address
461 RIVER PKWY, IDAHO FALLS, ID 83402-3314
(208) 542-4517
(208) 528-9501
Mailing address
3925 N AMMON RD, IDAHO FALLS, ID 83401-1313
(208) 521-6573
(208) 528-9501
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
807612600
ID
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
805608500
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
805608500
—
ID
05
—
807612600
—
ID
Enumeration date
01/10/2007
Last updated
06/25/2010
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