Provider Demographics
NPI:1013100890
Name:RUSSELLVILLE HOLDINGS, LLC
Entity Type:Organization
Organization Name:RUSSELLVILLE HOLDINGS, LLC
Other - Org Name:(PART B)
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-7220
Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11720 STATE ROUTE 27
Practice Address - Street 2:
Practice Address - City:HECTOR
Practice Address - State:AR
Practice Address - Zip Code:72843
Practice Address - Country:US
Practice Address - Phone:479-284-5001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSSELLVILLE HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-24
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F044Medicare PIN