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General NPI Number Information
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NPI Number | 1194644575
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Entity Type | Organization
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Legal Business Name | CADDO RIVER MEDICAL CLINIC PLLC
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Dates
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Enumeration Date | 07/10/2026
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Last Update Date | 07/10/2026
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Provider Practice Location Address
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Address Line | 180 HIGHWAY 70 E STE 11
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City | GLENWOOD
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State | AR
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Zip | 71943-8810
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Country | US
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Telephone | 870-828-1151
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Fax |
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Provider Business Mailing Address
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Address Line | 516 HIGHWAY 8 E
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City | GLENWOOD
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State | AR
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Zip | 71943-9222
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RICKEY EDNA MACK
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Credential | APRN
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Telephone | 870-828-1151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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