Provider Demographics
NPI:1902452345
Name:RIVER VALLEY PRIMARY CARE SERVICES
Entity Type:Organization
Organization Name:RIVER VALLEY PRIMARY CARE SERVICES
Other - Org Name:LAVACA WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EX. DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-431-2057
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-0130
Mailing Address - Country:US
Mailing Address - Phone:479-431-2050
Mailing Address - Fax:479-431-2058
Practice Address - Street 1:603 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:LAVACA
Practice Address - State:AR
Practice Address - Zip Code:72941-4129
Practice Address - Country:US
Practice Address - Phone:479-431-2050
Practice Address - Fax:479-431-2058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-12
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)