Healthcare Provider Details

I. General information

NPI: 1952349003
Provider Name (Legal Business Name): RIVER VALLEY PRIMARY CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9755 W STATE HIGHWAY 22
RATCLIFF AR
72951
US

IV. Provider business mailing address

9755 W STATE HIGHWAY 22 P.O. BOX 130
RATCLIFF AR
72951-9000
US

V. Phone/Fax

Practice location:
  • Phone: 479-431-2050
  • Fax:
Mailing address:
  • Phone: 479-635-5300
  • Fax:

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: CEO
Credential:
Phone: 479-431-2057