Basic Information
| Provider Information | |||||||||
| NPI: | 1275766909 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVER VALLEY PRIMARY CARE SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MULBERRY FAMILY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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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: | 421 N. MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | MULBERRY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799971484 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2009 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | JEROME | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 4794312057 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 180401749 | 05 | AR | MEDICAID | 771108449 | 05 | AR | MEDICAID |