Provider Demographics
NPI:1861074767
Name:RIVERSIDE LIFE ENRICHMENT CENTER INC
Entity type:Organization
Organization Name:RIVERSIDE LIFE ENRICHMENT CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEO H
Authorized Official - Middle Name:
Authorized Official - Last Name:COUTU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-626-3900
Mailing Address - Street 1:2104 E BURKE RD
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-9230
Mailing Address - Country:US
Mailing Address - Phone:802-626-3900
Mailing Address - Fax:
Practice Address - Street 1:2104 E BURKE RD
Practice Address - Street 2:
Practice Address - City:LYNDONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05851-9230
Practice Address - Country:US
Practice Address - Phone:802-626-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care