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General NPI Number Information
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NPI Number | 1487149043
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Entity Type | Organization
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Legal Business Name | RIVER VALLEY PRIMARY CARE, L.L.C.
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Dates
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Enumeration Date | 06/26/2018
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Last Update Date | 06/26/2018
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Provider Practice Location Address
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Address Line | 107 W BROADWAY ST
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City | SPIRO
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State | OK
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Zip | 74959-2417
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Country | US
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Telephone | 479-262-6069
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Fax |
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Provider Business Mailing Address
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Address Line | 403 GARRISON AVE APT 202
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City | FORT SMITH
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State | AR
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Zip | 72901-1959
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Country | US
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Telephone | 504-495-6772
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. FREDERICK JOSEPH FUOCO
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Credential |
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Telephone | 504-495-6772
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | N-5521
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 128797
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License Number State | AR
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