Basic Information
| Provider Information | |||||||||
| NPI: | 1144401233 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVER VALLEY PHYSICAL THERAPY SPINE AND JOINT CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 517 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | BRADLEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609151258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158027503 | ||||||||
| FaxNumber: | 8158027514 | ||||||||
| Practice Location | |||||||||
| Address1: | 517 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | BRADLEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609151258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158027503 | ||||||||
| FaxNumber: | 8158027514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2007 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | BREUKER | ||||||||
| AuthorizedOfficialFirstName: | GERARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8158027503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT, MSC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.