Healthcare Provider Details

I. General information

NPI: 1114562428
Provider Name (Legal Business Name): MOUNTAIN RIVER PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 WASHINGTON ST STE 1
RAVENSWOOD WV
26164-1730
US

IV. Provider business mailing address

415 36TH ST STE 100
PARKERSBURG WV
26101-1005
US

V. Phone/Fax

Practice location:
  • Phone: 304-917-3660
  • Fax: 304-917-3674
Mailing address:
  • Phone: 304-917-3660
  • Fax: 304-917-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTA ROGERS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 304-865-6778