Provider Demographics
NPI:1689725400
Name:RIVER CITY HEALTH CLINIC, INC
Entity Type:Organization
Organization Name:RIVER CITY HEALTH CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-332-0121
Mailing Address - Street 1:224 N FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5626
Mailing Address - Country:US
Mailing Address - Phone:573-332-0121
Mailing Address - Fax:
Practice Address - Street 1:224 N FREDERICK ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5626
Practice Address - Country:US
Practice Address - Phone:573-332-0121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO594649006Medicaid
263892Medicare ID - Type Unspecified