Provider Demographics
NPI:1427065556
Name:RUSSELLVILLE PRIMARY CARE CLINIC, INC.
Entity type:Organization
Organization Name:RUSSELLVILLE PRIMARY CARE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTI
Authorized Official - Middle Name:L
Authorized Official - Last Name:KIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-967-3980
Mailing Address - Street 1:PO BOX 9010
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9010
Mailing Address - Country:US
Mailing Address - Phone:479-967-3980
Mailing Address - Fax:479-967-6509
Practice Address - Street 1:2524 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2533
Practice Address - Country:US
Practice Address - Phone:479-967-3980
Practice Address - Fax:479-967-6509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
5F618Medicare PIN