Provider Demographics
NPI:1144401233
Name:RIVER VALLEY PHYSICAL THERAPY SPINE AND JOINT CENTER LLC
Entity Type:Organization
Organization Name:RIVER VALLEY PHYSICAL THERAPY SPINE AND JOINT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BREUKER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MSC
Authorized Official - Phone:815-802-7503
Mailing Address - Street 1:517 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1258
Mailing Address - Country:US
Mailing Address - Phone:815-802-7503
Mailing Address - Fax:815-802-7514
Practice Address - Street 1:517 E NORTH ST
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1258
Practice Address - Country:US
Practice Address - Phone:815-802-7503
Practice Address - Fax:815-802-7514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216224Medicare PIN