NPIMap

Organization Active NPI

River Valley Primary Care Services

Doing business as Mulberry Family Clinic

  • Federally Qualified Health Center (FQHC)
  • Mulberry, AR
National Provider Identifier
1275766909
Registry record updated Mar 8, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
RIVER VALLEY PRIMARY CARE SERVICES
Doing business as
Mulberry Family Clinic
Practice address
421 N. Main Street
Mulberry, AR 72947
Phone
(479) 997-1484
NPI assigned
Aug 28, 2009
Last updated
Mar 8, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 8, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jerome White
Title
C.E.O.
Phone
(479) 431-2057

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

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 names 1

  • Mulberry Family Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1275766909. Details of each certification follow.

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
CorporationNon-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
CorporationNon-profit
Incorporated
Sep 29, 2003 in AR
Enrollment address
421 N Main St
Mulberry, AR 72947-8574

Other NPIs with the same Medicare PAC ID 14

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 14

Other NPIs on the same Medicare enrollment 13

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 13

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D0469327Mulberry Family Clinic421 North Main Street, Mulberry, AR 72947Provider-performed microscopySep 23, 2027

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 12

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Mark Luerssen Individual Corporate DirectorBoard Member Nov 1, 2005 5%
Corporate DirectorBoard Member Sep 1, 2005 5%
Robert Redding Individual Corporate DirectorBoard Member Aug 1, 2013 5%
Greg Swartz Individual Corporate DirectorBoard Member May 1, 2009 5%
Corporate DirectorTreasurer Apr 1, 2009 5%
Gary O'Neal Individual Corporate DirectorBoard President Oct 1, 2005 5%
Corporate DirectorBoard President Sep 1, 2005
Jerome J White Individual Corporate OfficerCeo Sep 29, 2003 100%
W-2 Managing EmployeeCeo Sep 29, 2003 100%
Operational/Managerial ControlCeo Sep 29, 2003 100%
Corporate DirectorCeo Apr 4, 2005 5%
W-2 Managing EmployeeCeo Apr 4, 2005 5%
Bobby G McCartney Individual Corporate DirectorBoard Member Jul 27, 2016 5%
Corporate DirectorBoard Member Jun 1, 2015 5%
Mary Howard Individual Corporate DirectorSecretary Jul 1, 2006 5%
Corporate DirectorSecretary May 1, 2006 5%
Carmelita Adams Individual Corporate DirectorVice President Jul 1, 2011 5%
Corporate DirectorBoard Vice President May 1, 2011 5%
Shawn Miller Individual Corporate DirectorMedical Director May 1, 2017 5%
W-2 Managing EmployeeMedical Director May 1, 2017 5%
Sheila Peck Individual Corporate DirectorBoard Member Dec 1, 2022
Jessica Brown Individual Corporate DirectorBoard Member Dec 12, 2018
Laura Bryant Individual Corporate DirectorBoard Member Jun 1, 2021

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
River Valley Primary Care ServicesWaldron, AR, CCN 041940 Federally qualified health center Operational/Managerial Control (100%) May 1, 2018
Clarksville Behavioral HealthClarksville, AR, CCN 041987 Federally qualified health center 5% Or Greater Indirect Ownership Interest Sep 20, 2021
River Valley Primary Care ServicesCoal Hill, AR, CCN 041000 Federally qualified health center Operational/Managerial Control (100%) Dec 6, 2021

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1251417600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1646697600000",
    "number": "1275766909",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 130",
            "city": "RATCLIFF",
            "state": "AR",
            "postal_code": "729510130",
            "telephone_number": "479-635-5300",
            "fax_number": "479-635-2010"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "421 N. MAIN STREET",
            "city": "MULBERRY",
            "state": "AR",
            "postal_code": "72947",
            "telephone_number": "479-997-1484"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RIVER VALLEY PRIMARY CARE SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-08-28",
        "last_updated": "2022-03-08",
        "certification_date": "2022-03-08",
        "status": "A",
        "authorized_official_last_name": "WHITE",
        "authorized_official_first_name": "JEROME",
        "authorized_official_title_or_position": "C.E.O.",
        "authorized_official_telephone_number": "479-431-2057"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mulberry Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Mulberry Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mulberry, AR

Sources for this page

Verify at the official NPI Registry.