Provider Demographics
NPI:1043290109
Name:RIVER VALLEY PRIMARY CARE SERVICES INC
Entity type:Organization
Organization Name:RIVER VALLEY PRIMARY CARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-635-5300
Mailing Address - Street 1:9755 W STATE HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-9000
Mailing Address - Country:US
Mailing Address - Phone:479-635-5300
Mailing Address - Fax:479-635-4700
Practice Address - Street 1:9755 W STATE HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:RATCLIFF
Practice Address - State:AR
Practice Address - Zip Code:72951-9000
Practice Address - Country:US
Practice Address - Phone:479-635-5300
Practice Address - Fax:479-635-4700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5F279261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR041855Medicare ID - Type UnspecifiedUGS MILWAUKEE
AR5F279Medicare ID - Type UnspecifiedARK BC BS