Basic Information
| Provider Information | |||||||||
| NPI: | 1164438487 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN RIVER PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 36TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261011005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049173660 | ||||||||
| FaxNumber: | 3049173674 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 W. WAGNER STREET | ||||||||
| Address2: | |||||||||
| City: | ELLENBORO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048693888 | ||||||||
| FaxNumber: | 3048693444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 05/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | BURTON | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PT | ||||||||
| AuthorizedOfficialTelephone: | 3048656778 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, OCS, FAAOMPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 2701786 | 05 | OH | MEDICAID | DA4403 | 01 | MEDICARE ID TYPE UNSPEC | OTHER | 3810006084 | 05 | WV | MEDICAID |