Basic Information
| Provider Information | |||||||||
| NPI: | 1982277265 | ||||||||
| 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: | 106 N HILL ST | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728302961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796683292 | ||||||||
| FaxNumber: | 4796683293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2021 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | JEROME | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4794312057 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.