Organization
RIVERSIDE MEDICAL CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TOMMY WAGNER (OWNER)
(870) 561-3300
Entity
Organization
Contact information
Practice address
803 HWY 18, LAKE CITY, AR 72347-0505
(870) 237-1055
(870) 237-1054
Mailing address
PO BOX 910, MANILA, AR 72442-0910
(870) 561-3300
(870) 561-3307
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
187113002
—
AR
Enumeration date
10/07/2010
Last updated
08/02/2011
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