Provider Demographics
NPI:1750161980
Name:RIVERSIDE WELLNESS, LLC
Entity type:Organization
Organization Name:RIVERSIDE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHTON
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOLBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-417-9638
Mailing Address - Street 1:167 N 710 W
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5380
Mailing Address - Country:US
Mailing Address - Phone:208-417-9638
Mailing Address - Fax:
Practice Address - Street 1:167 N 710 W
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-5380
Practice Address - Country:US
Practice Address - Phone:208-417-9638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty