Provider Demographics
NPI:1245437490
Name:RIVER VALLEY MEDICAL CENTER FAMILY CLINIC LLC
Entity type:Organization
Organization Name:RIVER VALLEY MEDICAL CENTER FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROCK
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDELON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-226-8202
Mailing Address - Street 1:504 TEXAS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3526
Mailing Address - Country:US
Mailing Address - Phone:318-629-5321
Mailing Address - Fax:318-226-2805
Practice Address - Street 1:1652 STATE HIGHWAY 22 W
Practice Address - Street 2:
Practice Address - City:DARDANELLE
Practice Address - State:AR
Practice Address - Zip Code:72834-2909
Practice Address - Country:US
Practice Address - Phone:318-629-5321
Practice Address - Fax:318-629-5321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health