NPIMap

Organization Active NPI

River Valley Primary Care Services

Doing business as Waldron Family Clinic

  • Federally Qualified Health Center (FQHC)
  • Waldron, AR
National Provider Identifier
1992212013
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
Waldron Family Clinic
Practice address
2074 Rice Road
Waldron, AR 72958
Phone
(479) 635-5300
NPI assigned
Jan 10, 2018
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
Executive Director
Phone
(479) 635-0091

Specialties & licenses 1

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

Addresses

Primary practice location

2074 Rice Road
Waldron, AR 72958

Mailing address

PO Box 130
Ratcliff, AR 72951-0130
Phone (479) 635-0091

Other names 1

  • Waldron Family Clinic 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…
O20180604001516 AR Part A Provider - Federally Qualified Health Center (FQHC) 0042274276 Practice locations: Waldron, AR

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1992212013. Details of each certification follow.

Federally qualified health center certification: CCN 041940

Legal name
RIVER VALLEY PRIMARY CARE SERVICES
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 4, 2018
Last certification
Jun 4, 2018
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 29, 2003 in AR
Enrollment address
2074 Rice Road
Waldron, AR 72958-7435

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
04D2142818Waldron Family Clinic2074 Rice Road, Waldron, AR 72958Provider-performed microscopyJan 18, 2028

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 12

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

NameRoleSinceShare
River Valley Primary Care Services Organization, Ratcliff, AR Corporation, Non-profit Operational/Managerial Control May 1, 2018 100%
Mark Luerssen Individual Corporate DirectorBoard Member Nov 25, 2005 5%
Robert Redding Individual Corporate DirectorBoard Member Aug 25, 2013 5%
Greg Swartz Individual Corporate DirectorBoard Member May 24, 2009 5%
Sheila Peck Individual Corporate DirectorBoard Member Dec 1, 2022
Gary O'Neal Individual Corporate DirectorBoard Member Apr 4, 2005 5%
Jerome J White Individual Corporate DirectorExecutive Director Apr 4, 2005 5%
W-2 Managing EmployeeExecutive Director Apr 4, 2005 5%
Bobby G McCartney Individual Corporate DirectorBoard Member Jul 27, 2016 5%
Mary Howard Individual Corporate DirectorBoard Member Jul 24, 2006 5%
Jessica Brown Individual Corporate DirectorBoard Member Dec 12, 2018
Laura Bryant Individual Corporate DirectorBoard Member Jun 1, 2021
Carmelita Adams Individual Corporate DirectorBoard Member Jul 11, 2011 5%

Owners & managing parties with NPI records 14

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

View all 14

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
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 2

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

Facilities with the same owner 2

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 5

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": "1515542400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1612137600000",
    "number": "1992212013",
    "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": "479-635-0091",
            "fax_number": "479-635-2010"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2074 RICE ROAD",
            "city": "WALDRON",
            "state": "AR",
            "postal_code": "72958",
            "telephone_number": "479-635-5300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RIVER VALLEY PRIMARY CARE SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-01-10",
        "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": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "479-635-0091"
    },
    "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": "Waldron Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Waldron, AR

Sources for this page

Verify at the official NPI Registry.