Provider Demographics
NPI:1497411250
Name:RIVER OF LIFE HEALTH PLLC
Entity Type:Organization
Organization Name:RIVER OF LIFE HEALTH PLLC
Other - Org Name:CLINIC AT THE CAPITOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LADONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:870-949-1172
Mailing Address - Street 1:535 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-3637
Mailing Address - Country:US
Mailing Address - Phone:870-949-1172
Mailing Address - Fax:
Practice Address - Street 1:425 W CAPITOL AVE STE 1204
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-3405
Practice Address - Country:US
Practice Address - Phone:870-727-9283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-16
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty