Basic Information
| Provider Information | |||||||||
| NPI: | 1073186458 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER VALLEY PRIMARY CARE SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | RATCLIFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729510130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794312057 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 N WALNUT AVE STE D | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729443522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794312050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2021 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | JEROME | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4794312050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.