Provider Demographics
NPI:1184009086
Name:RIVER HEALTH CARE, LLC
Entity Type:Organization
Organization Name:RIVER HEALTH CARE, LLC
Other - Org Name:MAGNOLIA FOOT CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:CRUEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-941-6386
Mailing Address - Street 1:4510 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-6016
Mailing Address - Country:US
Mailing Address - Phone:601-941-6386
Mailing Address - Fax:
Practice Address - Street 1:426 ABBEY WOODS
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-7719
Practice Address - Country:US
Practice Address - Phone:601-941-6386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVER HEALTH CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80152213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty