Provider Demographics
NPI:1043796626
Name:RIVER VALLEY PRIMARY CARE OF POTEAU, LLC
Entity Type:Organization
Organization Name:RIVER VALLEY PRIMARY CARE OF POTEAU, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDRICK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FUOCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-495-6772
Mailing Address - Street 1:403 GARRISON AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-1959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:502 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4216
Practice Address - Country:US
Practice Address - Phone:504-495-6772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN5521207Q00000X
AR128797363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty