=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053037218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER VALLEY SURGERY CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2022
-----------------------------------------------------
Last Update Date | 10/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3110 W MAIN ST
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72801-2455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-967-7770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3110 W MAIN ST
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72801-2455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-967-7770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AHMAD RAFI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 479-967-7770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------