Basic Information
| Provider Information | |||||||||
| NPI: | 1982644753 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER VALLEY PEDIATRIC THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9178 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728119178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799684273 | ||||||||
| FaxNumber: | 4799681363 | ||||||||
| Practice Location | |||||||||
| Address1: | 2703 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728012456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4798905494 | ||||||||
| FaxNumber: | 4799680069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHITLOCK | ||||||||
| AuthorizedOfficialFirstName: | SARA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4798905494 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P0010X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pediatric Rehabilitation Medicine |
ID Information
| ID | Type | State | Issuer | Description | BCBS | 01 | AR | BCBS | OTHER |