Provider Demographics
NPI:1043548563
Name:RIVER DISTRICT REHABILITATION, LLC
Entity Type:Organization
Organization Name:RIVER DISTRICT REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:BATIFORA
Authorized Official - Last Name:DISTRITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-885-2820
Mailing Address - Street 1:12402 TWEED DR
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-8959
Mailing Address - Country:US
Mailing Address - Phone:815-885-2820
Mailing Address - Fax:815-977-4594
Practice Address - Street 1:119 N WYMAN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-1107
Practice Address - Country:US
Practice Address - Phone:815-977-4490
Practice Address - Fax:815-977-4594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1990943305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service