=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801491568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAIN RIVER PHYSICAL THERAPY SPECIALISTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2020
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10430 STATE ROUTE 550 STE A
-----------------------------------------------------
City | VINCENT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45784-5514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-760-8593
-----------------------------------------------------
Fax | 740-760-8594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1650 LYNDON FARM CT STE 300
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40223-5005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-917-3660
-----------------------------------------------------
Fax | 304-917-3664
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/MEMBER
-----------------------------------------------------
Name | BURTON REED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-917-3660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------