=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619133394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER VALLEY URGENT CARE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2008
-----------------------------------------------------
Last Update Date | 02/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 WE KNIGHT DRIVE
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-6248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-709-6729
-----------------------------------------------------
Fax | 479-709-8687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3500 WE KNIGHT DR
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-6248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-709-8686
-----------------------------------------------------
Fax | 479-709-8687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOHN P WEDDLE
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 479-709-8686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------