Healthcare Provider Details

I. General information

NPI: 1932150943
Provider Name (Legal Business Name): RUSSELLVILLE HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2006
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11720 SR 27
HECTOR AR
72843-8712
US

IV. Provider business mailing address

11720 SR 27
HECTOR AR
72843-8712
US

V. Phone/Fax

Practice location:
  • Phone: 479-284-5001
  • Fax: 479-284-4210
Mailing address:
  • Phone: 479-968-2841
  • Fax: 479-968-8189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA001233
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number4192
License Number StateAR

VIII. Authorized Official

Name: TERRANCE DILLON
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 502-596-7220