Healthcare Provider Details

I. General information

NPI: 1699010991
Provider Name (Legal Business Name): RIVER VALLEY PRIMARY CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 CHILDERS AVE
LAMAR AR
72846-8161
US

IV. Provider business mailing address

PO BOX 130
RATCLIFF AR
72951-0130
US

V. Phone/Fax

Practice location:
  • Phone: 479-668-4881
  • Fax:
Mailing address:
  • Phone: 479-635-5300
  • Fax: 479-635-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. JEROME JOSEPH WHITE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 479-431-2050