Healthcare Provider Details

I. General information

NPI: 1831820422
Provider Name (Legal Business Name): MOBILE WATER THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37903 EUCLID AVE
WILLOUGHBY OH
44094-5978
US

IV. Provider business mailing address

PO BOX 1502
WILLOUGHBY OH
44096-1502
US

V. Phone/Fax

Practice location:
  • Phone: 216-406-1195
  • Fax:
Mailing address:
  • Phone: 216-406-1195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LOLITA RICHMOND
Title or Position: OWNER
Credential:
Phone: 928-374-2722