Provider Demographics
NPI:1588738272
Name:RIVER WEST CLINIC CORP.
Entity type:Organization
Organization Name:RIVER WEST CLINIC CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP LICENSURE
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:FULNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-253-0771
Mailing Address - Street 1:PO BOX 2121
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-2121
Mailing Address - Country:US
Mailing Address - Phone:502-253-0771
Mailing Address - Fax:502-253-0683
Practice Address - Street 1:59335 RIVER WEST DR
Practice Address - Street 2:SUITE B
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-6553
Practice Address - Country:US
Practice Address - Phone:225-687-5594
Practice Address - Fax:225-687-5595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CD36Medicare PIN