Healthcare Provider Details

I. General information

NPI: 1528248036
Provider Name (Legal Business Name): RIVERVIEW PHYSICAL THERAPY AND REHAB,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 WATER ST
PORT HURON MI
48060-4136
US

IV. Provider business mailing address

1702 WATER ST
PORT HURON MI
48060-4136
US

V. Phone/Fax

Practice location:
  • Phone: 810-966-9102
  • Fax: 810-966-9104
Mailing address:
  • Phone: 810-966-9102
  • Fax: 810-966-9104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501008202
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201003768
License Number StateMI

VIII. Authorized Official

Name: MR. HARGOPAL TEKUMULLA
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 810-966-9102