Healthcare Provider Details

I. General information

NPI: 1184009086
Provider Name (Legal Business Name): RIVER HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 ABBEY WOODS
BRANDON MS
39047-7719
US

IV. Provider business mailing address

4510 OFFICE PARK DR
JACKSON MS
39206-6016
US

V. Phone/Fax

Practice location:
  • Phone: 601-941-6386
  • Fax:
Mailing address:
  • Phone: 601-941-6386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number80152
License Number StateMS

VIII. Authorized Official

Name: LARRY K CRUEL
Title or Position: OWNER / PRESIDENT
Credential: DPM
Phone: 601-941-6386