=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487229977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURNING RIVER PHYSICAL THERAPY AND WELLNESS CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2021
-----------------------------------------------------
Last Update Date | 10/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23800 COMMERCE PARK STE M
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-5828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-467-1138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32980 CREEKSIDE DR
-----------------------------------------------------
City | PEPPER PIKE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44124-5273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BENJAMIN WHITE
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 440-467-1138
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------