MEDICARE: RIVER VALLEY PHYSICAL THERAPY SPINE AND JOINT CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1144401233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER VALLEY PHYSICAL THERAPY SPINE AND JOINT CENTER LLC

Provider Business Mailing Address
First Line	:	517 E NORTH ST
Second Line	:
City	:	BRADLEY
State	:	IL
Zip	:	60915-1258
Country	:	US
Telephone Number	:	815-802-7503
Fax Number	:	815-802-7514

Provider Business Practice Location Address
First Line	:	517 E NORTH ST
Second Line	:
City	:	BRADLEY
State	:	IL
Zip	:	60915-1258
Country	:	US
Telephone Number	:	815-802-7503
Fax Number	:	815-802-7514

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. GERARD BREUKER
Credential	:	PT, MSC
Telephone Number	:	815-802-7503

Provider Enumeration Date	:	11/17/2007
Last Update Date	:	11/17/2015

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