Provider Demographics
NPI:1083607220
Name:RIVER CITY REHABILITATION LLC
Entity Type:Organization
Organization Name:RIVER CITY REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ASHFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-335-8332
Mailing Address - Street 1:1707 SOUTH COLORADO
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703
Mailing Address - Country:US
Mailing Address - Phone:662-335-8332
Mailing Address - Fax:662-335-8852
Practice Address - Street 1:1707 SOUTH COLORADO
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703
Practice Address - Country:US
Practice Address - Phone:662-335-8332
Practice Address - Fax:662-335-8852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1045225100000X
MSPT0713225100000X
MSOT0169225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015486Medicaid
MS09015486Medicaid
MS=========OtherBCBS
MS3974490001Medicare NSC