Provider Demographics
NPI:1376841064
Name:BLACK RIVER HEALTHCARE, INC.
Entity Type:Organization
Organization Name:BLACK RIVER HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:573-727-9793
Mailing Address - Street 1:1879 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2833
Mailing Address - Country:US
Mailing Address - Phone:573-727-9793
Mailing Address - Fax:573-785-1854
Practice Address - Street 1:1879 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2833
Practice Address - Country:US
Practice Address - Phone:573-727-9793
Practice Address - Fax:573-785-1854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-04
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health