River Valley Primary Care Services
Organization Active NPI Federally Qualified Health Center (FQHC) · Mulberry, AR
NPI 1275766909 · NPPES record last updated Mar 8, 2022
Key facts
- NPI
- 1275766909
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- RIVER VALLEY PRIMARY CARE SERVICES
- Practice address
- 421 N. Main Street
Mulberry, AR 72947 - Phone
- (479) 997-1484
- NPI assigned
- Aug 28, 2009
- Organization subpart
- No
Authorized official
- Name
- Jerome White
- Title
- C.E.O.
- Phone
- (479) 431-2057
Owners & managing parties with NPI records 1
-
Shawn Scarberry Miller, M.D.
Owned or controlled facilities with NPI records 3
Other NPIs on the same Medicare enrollment 13
Other NPIs with the same Medicare PAC ID 14
Practitioners 39
-
Jonalee Vogel, APRN
-
Michelle Cameron, FNP
-
Amber R Acord, PA
-
Taylor Ajtun, RD
-
Lauren Hope Andrews, APRN, FNP-C, PMHNP-C
-
Colleen Jane Atchley, APRN
-
Nathan Bennett, D.O.
-
Sherilyn Jo Bennett, APRN
-
Kellie L Berry-Hert, NURSE PRACTITIONER
-
Jennifer E Burks, MD
-
James Leon Cheshier, M.D., P.A.
-
Haley Duff, APRN
-
Heather Erwin, WHNP-BC
-
Wendy A. Gaston, APN
-
Ashley N Gattis, NP
-
Janet Elizabeth Guyer, M.D.
-
Kelly Jo Hubbard, APN
-
Glenda Marie King, APRN
-
Roxanne Marshall, M.D.
-
Zachary Heath McBroom, APRN, FNP-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 04D0469327 | Mulberry Family Clinic | Provider-performed microscopy | Sep 23, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in AR
Federally qualified health center certification: CCN 041867
- Legal name
- RIVER VALLEY PRIMARY CARE SERVICES
- Doing business as
- NORTHSIDE CLINIC AT 6TH STREET
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Mar 19, 2009
- Last certification
- Mar 19, 2009
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Sep 29, 2003 in AR
- Enrollment address
- 3202 N 6TH St
Fort Smith, AR 72904-4164
Federally qualified health center certification: CCN 041872
- Legal name
- RIVER VALLEY PRIMARY CARE SERVICES
- Doing business as
- MULBERRY FAMILY CLINIC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Nov 18, 2009
- Last certification
- Nov 18, 2009
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Sep 29, 2003 in AR
- Enrollment address
- 421 N Main St
Mulberry, AR 72947-8574
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Mark Luerssen |
Corporate Director |
Nov 1, 2005 | 5% |
| Corporate Director |
Sep 1, 2005 | 5% | |
| Robert Redding |
Corporate Director |
Aug 1, 2013 | 5% |
| Greg Swartz |
Corporate Director |
May 1, 2009 | 5% |
| Corporate Director |
Apr 1, 2009 | 5% | |
| Gary O'Neal |
Corporate Director |
Oct 1, 2005 | 5% |
| Corporate Director |
Sep 1, 2005 | ||
| Jerome J White |
Corporate Officer |
Sep 29, 2003 | 100% |
| W-2 Managing Employee |
Sep 29, 2003 | 100% | |
| Operational/Managerial Control |
Sep 29, 2003 | 100% | |
| Corporate Director |
Apr 4, 2005 | 5% | |
| W-2 Managing Employee |
Apr 4, 2005 | 5% | |
| Bobby G McCartney |
Corporate Director |
Jul 27, 2016 | 5% |
| Corporate Director |
Jun 1, 2015 | 5% | |
| Mary Howard |
Corporate Director |
Jul 1, 2006 | 5% |
| Corporate Director |
May 1, 2006 | 5% | |
| Carmelita Adams |
Corporate Director |
Jul 1, 2011 | 5% |
| Corporate Director |
May 1, 2011 | 5% | |
| Shawn Miller |
Corporate Director |
May 1, 2017 | 5% |
| W-2 Managing Employee |
May 1, 2017 | 5% | |
| Sheila Peck |
Corporate Director |
Dec 1, 2022 | |
| Jessica Brown |
Corporate Director |
Dec 12, 2018 | |
| Laura Bryant |
Corporate Director |
Jun 1, 2021 |
All facility ownership & control disclosures 3
| Facility | Type | Role | Since |
|---|---|---|---|
| River Valley Primary Care Services |
Federally qualified health center | Operational/Managerial Control (100%) | May 1, 2018 |
| Clarksville Behavioral Health |
Federally qualified health center | 5% Or Greater Indirect Ownership Interest | Sep 20, 2021 |
| River Valley Primary Care Services |
Federally qualified health center | Operational/Managerial Control (100%) | Dec 6, 2021 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20050503001398 | AR | Part B Supplier - Clinic/Group Practice | 0042274276 |
Receives reassigned benefits from 41 practitioners 13 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Waldron, AR; Ratcliff, AR; Mulberry, AR; Mountainburg, AR; Lavaca, AR; Lamar, AR; Fort Smith, AR; Coal Hill, AR… |
| O20090311000506 | AR | Part a Provider - Federally Qualified Health Center (FQHC) | 0042274276 |
5 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Fort Smith, AR |
| O20091118000575 | AR | Part a Provider - Federally Qualified Health Center (FQHC) | 0042274276 | Practice locations: Mulberry, AR |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
421 N. Main Street
Mulberry, AR 72947
Mailing address
PO Box 130
Ratcliff, AR 72951-0130
Phone (479) 635-5300
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 180401749 | Medicaid | AR | |
| 771108449 | Medicaid | AR |
Other names
- Mulberry Family Clinic
Other providers in Mulberry, AR
- Perspectives Behavioral Health Management, LLC
- Kelli L. Rippy
- River Valley Physical Therapy
- River Valley Primary Care
- River Valley Primary Care Services
- Andrew Scott
- Stable Steps, LLC
- Vekensha Tengbeh
- The Guidance Center - RCF Mulberry
- Jodie Thorsen
All providers in Mulberry, AR · Federally Qualified Health Center (FQHC) in Arkansas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 8, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.