Basic Information
| Provider Information | |||||||||
| NPI: | 1225296619 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER VALLEY PRIMARY CARE SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | RATCLIFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729510130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796355300 | ||||||||
| FaxNumber: | 4796352010 | ||||||||
| Practice Location | |||||||||
| Address1: | 9755 W STATE HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | RATCLIFF | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729519000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796355300 | ||||||||
| FaxNumber: | 4796352010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2008 | ||||||||
| LastUpdateDate: | 06/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4796355300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 156152631 | 05 | AR | MEDICAID |