Provider Demographics
NPI:1174222756
Name:RIVERTOWN CAPITAL INC
Entity type:Organization
Organization Name:RIVERTOWN CAPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GRADY
Authorized Official - Middle Name:W
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:334-480-4015
Mailing Address - Street 1:PO BOX 914
Mailing Address - Street 2:
Mailing Address - City:SMITHS STATION
Mailing Address - State:AL
Mailing Address - Zip Code:36877-0914
Mailing Address - Country:US
Mailing Address - Phone:706-289-7546
Mailing Address - Fax:
Practice Address - Street 1:2013 HIGHWAY 280 BYP
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-3687
Practice Address - Country:US
Practice Address - Phone:706-289-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529907970Medicaid