| Name: | RIVERSIDE FAMILY HEALTH, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 29 May 2012 (12 years ago) (Companies founded in May 2012) |
| Entity Number: | 000-059-246 |
| Register Number: | 000059246 |
| Place of Formation: | Morgan County |
| Registered Office Street Address: | 1610 PERKINS WOOD ROADSOMERVILLE, AL 35670-4653 |
Activities
ANY LAWFUL BUSINESS
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1851652416 | 2012-05-30 | 2023-07-19 | 1501 7TH ST SE STE A, DECATUR, AL, 356013375, US | 1501 7TH ST SE STE A, DECATUR, AL, 356013375, US | |||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 256-355-7665 |
| Fax | 2566863241 |
Authorized person
| Name | CRYSTAL LEANN LANDRUM |
| Role | CEO |
| Phone | 2563557665 |
Taxonomy
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| License Number | 1-093034 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 138745 |
| State | AL |
| Issuer | CAQH |
| Number | 12404856 |
| State | AL |
| Issuer | MEDICAID |
| Number | 140473 |
| State | AL |
| Issuer | BCBS |
| Number | 51126863 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| LANDRUM, CRYSTAL R | Agent | 1610 PERKINS WOOD ROADSOMERVILLE, AL 35670-4653 |
| Name | Role | Address |
|---|---|---|
| LANDRUM, CRYSTAL R | Organizer | 1610 PERKINS WOOD ROADSOMERVILLE, AL 35670-4653 |
Date of last update: 31 Jul 2024
Sources: Alabama Secretary of State
