Healthcare Provider Details

I. General information

NPI: 1205247004
Provider Name (Legal Business Name): RIVER CITY MINISTRY OF PULASKI COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 E WASHINGTON AVE
NORTH LITTLE ROCK AR
72114-5853
US

IV. Provider business mailing address

1021 E WASHINGTON AVE
NORTH LITTLE ROCK AR
72114-5853
US

V. Phone/Fax

Practice location:
  • Phone: 501-376-6694
  • Fax: 501-376-6695
Mailing address:
  • Phone: 501-376-6694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC6822
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberM001021
License Number StateAR

VIII. Authorized Official

Name: MELANIE WARE
Title or Position: MEDICAL MANAGER
Credential: A.P.N.
Phone: 501-376-6694