Provider Demographics
NPI:1720512601
Name:RIVER VALLEY MEDICAL CLINIC
Entity Type:Organization
Organization Name:RIVER VALLEY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FUOCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-495-6772
Mailing Address - Street 1:2719 BRYAN RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-5031
Mailing Address - Country:US
Mailing Address - Phone:918-208-4868
Mailing Address - Fax:
Practice Address - Street 1:2719 BRYAN RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-5031
Practice Address - Country:US
Practice Address - Phone:918-208-4868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2230207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty