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General NPI Number Information
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NPI Number | 1275985012
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Entity Type | Organization
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Legal Business Name | RIVERFRONT URGENT CARE CENTER LLC
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Dates
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Enumeration Date | 07/05/2016
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Last Update Date | 02/07/2017
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Provider Practice Location Address
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Address Line | 107 FRONT ST STE 2138
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City | VIDALIA
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State | LA
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Zip | 71373-2836
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Country | US
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Telephone | 318-336-2219
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Fax | 318-336-6067
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Provider Business Mailing Address
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Address Line | 107 FRONT ST STE 2138
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City | VIDALIA
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State | LA
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Zip | 71373-2836
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Country | US
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Telephone | 318-336-2219
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Fax | 318-336-6067
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Authorized Official
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Title or Position | OWNER
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Name | JOHN H FAIRBANKS
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Credential | M.D.
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Telephone | 318-336-2212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 017268
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | 017268
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License Number State | LA
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