Provider Demographics
NPI:1952349003
Name:RIVER VALLEY PRIMARY CARE SERVICES
Entity Type:Organization
Organization Name:RIVER VALLEY PRIMARY CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-431-2057
Mailing Address - Street 1:9755 W STATE HIGHWAY 22
Mailing Address - Street 2:P.O. BOX 130
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-9000
Mailing Address - Country:US
Mailing Address - Phone:479-635-5300
Mailing Address - Fax:
Practice Address - Street 1:9755 W STATE HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:RATCLIFF
Practice Address - State:AR
Practice Address - Zip Code:72951
Practice Address - Country:US
Practice Address - Phone:479-431-2050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156152631Medicaid
AR770106649Medicaid
AR156966749Medicaid
AR5F279Medicare ID - Type Unspecified
AR156966749Medicaid