Healthcare Provider Details

I. General information

NPI: 1306901806
Provider Name (Legal Business Name): RIVER VALLEY MOBILE RADIOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 STREAM RD
RUSSELLVILLE AR
72802-1824
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 479-857-4002
  • Fax: 479-968-1363
Mailing address:
  • Phone: 479-968-4273
  • Fax: 479-968-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number StateAR

VIII. Authorized Official

Name: RICK BALENTINE
Title or Position: OWNER
Credential:
Phone: 479-857-4002