NPIMap

Organization Active NPI

River Valley Primary Care Services

Doing business as Lavaca Wellness Center

  • Federally Qualified Health Center (FQHC)
  • Lavaca, AR
National Provider Identifier
1902452345
Registry record updated Feb 1, 2021
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
Lavaca Wellness Center
Practice address
603 S Division St
Lavaca, AR 72941-4129
Phone
(479) 431-2050
Fax
(479) 431-2058
NPI assigned
Aug 12, 2019
Last updated
Feb 1, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 1, 2021

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

Authorized official

Name
Jerome J White
Title
Ex. Director
Phone
(479) 431-2057

Specialties & licenses 1

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

Addresses

Primary practice location

603 S Division St
Lavaca, AR 72941-4129

Mailing address

PO Box 130
Ratcliff, AR 72951-0130
Phone (479) 431-2050

Other names 1

  • Lavaca Wellness Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR2 enrollments

Enrollment records 2

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…
O20191016001463 AR Part A Provider - Federally Qualified Health Center (FQHC) 0042274276 Practice locations: Lavaca, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1902452345. Details of each certification follow.

Federally qualified health center certification: CCN 041955

Legal name
RIVER VALLEY PRIMARY CARE SERVICES
Doing business as
LAVACA WELLNESS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 14, 2019
Last certification
Oct 14, 2019
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
603 S Division St
Lavaca, AR 72941-4129

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
04D2172054Lavaca Wellness Center603 S Division St, Lavaca, AR 72941Provider-performed microscopySep 12, 2027

National Provider Directory

National Provider Directory
Tax ID family
River Vly Primary Care SVCS20 organizations share this tax ID, including this one

Other organizations with this tax ID 19

Organizations that report the same tax identification number in the National Provider Directory.

View all 19

Ownership & related parties

All disclosed owners & managing parties 10

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 Sep 1, 2005
Robert Redding Individual Corporate DirectorBoard Member Aug 1, 2013
Greg Swartz Individual Corporate DirectorTreasurer Apr 1, 2009
Sheila Peck Individual Corporate DirectorBoard Member Dec 1, 2022
Gary O'Neal Individual Corporate DirectorBoard President Sep 1, 2005
Jerome J White Individual Corporate DirectorCeo Apr 4, 2005
W-2 Managing EmployeeCeo Apr 4, 2005
Bobby G McCartney Individual Corporate DirectorBoard Member Jun 1, 2015
Mary Howard Individual Corporate DirectorSecretary May 1, 2006
Laura Bryant Individual Corporate DirectorBoard Member Jun 1, 2021
Carmelita Adams Individual Corporate DirectorBoard Vice President May 1, 2011

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.

NPI Registry JSON

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

{
    "created_epoch": "1565568000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1612137600000",
    "number": "1902452345",
    "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": "479-431-2050",
            "fax_number": "479-431-2058"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "603 S DIVISION ST",
            "city": "LAVACA",
            "state": "AR",
            "postal_code": "729414129",
            "telephone_number": "479-431-2050",
            "fax_number": "479-431-2058"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RIVER VALLEY PRIMARY CARE SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-12",
        "last_updated": "2021-02-01",
        "certification_date": "2021-02-01",
        "status": "A",
        "authorized_official_last_name": "WHITE",
        "authorized_official_first_name": "JEROME",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "EX. DIRECTOR",
        "authorized_official_telephone_number": "479-431-2057"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lavaca Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Lavaca Wellness Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lavaca, AR

Sources for this page

Verify at the official NPI Registry.