Provider Demographics
NPI:1083740047
Name:ARKANSAS VERDIGRIS VALLEY HEALTH CENTERS, INC.
Entity Type:Organization
Organization Name:ARKANSAS VERDIGRIS VALLEY HEALTH CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-483-0111
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:OK
Mailing Address - Zip Code:74454-0334
Mailing Address - Country:US
Mailing Address - Phone:918-483-0213
Mailing Address - Fax:918-483-4174
Practice Address - Street 1:505 S MAIN
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:OK
Practice Address - Zip Code:74454
Practice Address - Country:US
Practice Address - Phone:918-483-0111
Practice Address - Fax:918-483-0112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200109570AMedicaid
OK200109570AMedicaid