1538111398 NPI number — RUSSELLVILLE HOLDINGS 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 1538111398 NPI number — RUSSELLVILLE HOLDINGS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSSELLVILLE HOLDINGS 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:
6
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:
1538111398
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 849117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-9117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-968-2841
Provider Business Mailing Address Fax Number:
479-968-8189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1808 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72801-2724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-968-2841
Provider Business Practice Location Address Fax Number:
479-968-8189
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DILLON
Authorized Official First Name:
TERRANCE
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
502-596-7220

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  4193 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 152329105 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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