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General NPI Number Information
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NPI Number | 1043548563
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Entity Type | Organization
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Legal Business Name | RIVER DISTRICT REHABILITATION, LLC
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Dates
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Enumeration Date | 11/20/2009
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Last Update Date | 11/20/2009
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Provider Practice Location Address
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Address Line | 119 N WYMAN ST
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City | ROCKFORD
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State | IL
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Zip | 61101-1107
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Country | US
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Telephone | 815-977-4490
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Fax | 815-977-4594
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Provider Business Mailing Address
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Address Line | 12402 TWEED DR
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City | LOVES PARK
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State | IL
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Zip | 61111-8959
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Country | US
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Telephone | 815-885-2820
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Fax | 815-977-4594
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Authorized Official
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Title or Position | OWNER
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Name | MR. EDWIN BATIFORA DISTRITO
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Credential |
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Telephone | 815-885-2820
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 1990943
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License Number State | IL
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