Provider Demographics
NPI:1104872522
Name:WHITE RIVER HEALTHCARE LLC
Entity type:Organization
Organization Name:WHITE RIVER HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-523-4333
Mailing Address - Street 1:601 CALICO STREET
Mailing Address - Street 2:
Mailing Address - City:CALICO ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72519
Mailing Address - Country:US
Mailing Address - Phone:870-297-3719
Mailing Address - Fax:870-297-3732
Practice Address - Street 1:1005 MCLAIN ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3529
Practice Address - Country:US
Practice Address - Phone:870-523-4333
Practice Address - Fax:870-523-4341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR737314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR045401Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER