# RIVERSIDE MEDICAL CLINIC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1811206923
- **Authorized official:** TOMMY WAGNER (OWNER)
- **Authorized official phone:** (870) 561-3300

## Contact information

- **Practice address:** 803 HWY 18, LAKE CITY, AR 72347-0505
- **Practice address phone:** (870) 237-1055
- **Practice address fax:** (870) 237-1054
- **Mailing address:** PO BOX 910, MANILA, AR 72442-0910
- **Mailing address phone:** (870) 561-3300
- **Mailing address fax:** (870) 561-3307

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 10/07/2010
- **Last updated:** 08/02/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 187113002 | — | AR |