Provider Demographics
NPI:1962516120
Name:RIVERTOWN MEDICAL CLINIC
Entity type:Organization
Organization Name:RIVERTOWN MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCOTR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:LOKKESMOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-507-1213
Mailing Address - Street 1:4328 ARMOUR RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5204
Mailing Address - Country:US
Mailing Address - Phone:706-507-1213
Mailing Address - Fax:706-507-1217
Practice Address - Street 1:4328 ARMOUR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5204
Practice Address - Country:US
Practice Address - Phone:706-507-1213
Practice Address - Fax:706-507-1217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA032941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty