1316251051 NPI number — RIVERPARK PRIMARY HEALTH CLINIC, LLC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316251051 NPI number — RIVERPARK PRIMARY HEALTH CLINIC, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERPARK PRIMARY HEALTH CLINIC, LLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316251051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 FRONT STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-336-2218
Provider Business Mailing Address Fax Number:
318-336-6066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 FRONT STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-336-2218
Provider Business Practice Location Address Fax Number:
318-336-6066
Provider Enumeration Date:
08/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MABRY
Authorized Official First Name:
DEANA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
318-336-2218

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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