Provider Demographics
NPI:1164438487
Name:MOUNTAIN RIVER PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:MOUNTAIN RIVER PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:
Authorized Official - First Name:BURTON
Authorized Official - Middle Name:R
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS, FAAOMPT
Authorized Official - Phone:304-865-6778
Mailing Address - Street 1:415 36TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-1005
Mailing Address - Country:US
Mailing Address - Phone:304-917-3660
Mailing Address - Fax:304-917-3674
Practice Address - Street 1:117 W. WAGNER STREET
Practice Address - Street 2:
Practice Address - City:ELLENBORO
Practice Address - State:WV
Practice Address - Zip Code:26346
Practice Address - Country:US
Practice Address - Phone:304-869-3888
Practice Address - Fax:304-869-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2701786Medicaid
DA4403OtherMEDICARE ID TYPE UNSPEC
WV3810006084Medicaid
DA4403OtherMEDICARE ID TYPE UNSPEC