Provider Demographics
NPI:1508846015
Name:WHITE RIVER HEALTH SYSTEM, INC.
Entity Type:Organization
Organization Name:WHITE RIVER HEALTH SYSTEM, INC.
Other - Org Name:HARDY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-262-6039
Mailing Address - Street 1:197 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:72529-7314
Mailing Address - Country:US
Mailing Address - Phone:870-257-6070
Mailing Address - Fax:870-257-7667
Practice Address - Street 1:197 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CHEROKEE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:72529-7314
Practice Address - Country:US
Practice Address - Phone:870-257-6070
Practice Address - Fax:870-257-7667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C481Medicare ID - Type Unspecified