Basic Information
Provider Information | |||||||||
NPI: | 1104872522 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WHITE RIVER HEALTHCARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 601 CALICO STREET | ||||||||
Address2: |   | ||||||||
City: | CALICO ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 72519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8702973719 | ||||||||
FaxNumber: | 8702973732 | ||||||||
Practice Location | |||||||||
Address1: | 1005 MCLAIN ST | ||||||||
Address2: |   | ||||||||
City: | NEWPORT | ||||||||
State: | AR | ||||||||
PostalCode: | 721123529 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8705234333 | ||||||||
FaxNumber: | 8705234341 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2006 | ||||||||
LastUpdateDate: | 04/10/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SAMPSON | ||||||||
AuthorizedOfficialFirstName: | RICK | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | AGENT | ||||||||
AuthorizedOfficialTelephone: | 8705234333 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 737 | AR | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.