Basic Information
| Provider Information | |||||||||
| NPI: | 1366724874 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROCK VALLEY PHYSICAL THERAPY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 43RD AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 931 13TH AVE N | ||||||||
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| City: | CLINTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527325072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5632437814 | ||||||||
| FaxNumber: | 5632432441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2011 | ||||||||
| LastUpdateDate: | 09/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | BOLDT | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3097432070 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0565937 | 05 | IA | MEDICAID |