Provider Demographics
NPI:1275985012
Name:RIVERFRONT URGENT CARE CENTER LLC
Entity Type:Organization
Organization Name:RIVERFRONT URGENT CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-336-2212
Mailing Address - Street 1:107 FRONT ST
Mailing Address - Street 2:STE 2138
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-2836
Mailing Address - Country:US
Mailing Address - Phone:318-336-2219
Mailing Address - Fax:318-336-6067
Practice Address - Street 1:107 FRONT ST
Practice Address - Street 2:STE 2138
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-2836
Practice Address - Country:US
Practice Address - Phone:318-336-2219
Practice Address - Fax:318-336-6067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017268207X00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty