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General NPI Number Information
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NPI Number | 1457899809
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Entity Type | Organization
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Legal Business Name | MOUNTAIN RIDGE PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 02/06/2017
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Last Update Date | 02/06/2017
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Provider Practice Location Address
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Address Line | 6000 COOMBS FARM DRIVE SUITE 202B
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City | MORGANTOWN
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State | WV
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Zip | 26508
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Country | US
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Telephone | 304-685-6064
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Fax |
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Provider Business Mailing Address
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Address Line | 6000 COOMBS FARM DRIVE SUITE 202B
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City | MORGANTOWN
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State | WV
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Zip | 26508
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Country | US
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Telephone | 304-685-6064
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Fax |
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Authorized Official
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Title or Position | OWNER, PHYSICAL THERAPIST
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Name | DR. DEREK D CLARK
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Credential | DPT, PT, MS, CSCS
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Telephone | 304-685-6064
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 2714
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License Number State | WV
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