Healthcare Provider Details

I. General information

NPI: 1902452345
Provider Name (Legal Business Name): RIVER VALLEY PRIMARY CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 S DIVISION ST
LAVACA AR
72941-4129
US

IV. Provider business mailing address

PO BOX 130
RATCLIFF AR
72951-0130
US

V. Phone/Fax

Practice location:
  • Phone: 479-431-2050
  • Fax: 479-431-2058
Mailing address:
  • Phone: 479-431-2050
  • Fax: 479-431-2058

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: JEROME J WHITE
Title or Position: EX. DIRECTOR
Credential:
Phone: 479-431-2057