Provider Demographics
NPI:1336282839
Name:ROCK VALLEY PHYSICAL THERAPY CENTER
Entity Type:Organization
Organization Name:ROCK VALLEY PHYSICAL THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-743-2070
Mailing Address - Street 1:850 43RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:902 ILLINI DRIVE
Practice Address - Street 2:
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282
Practice Address - Country:US
Practice Address - Phone:309-796-3450
Practice Address - Fax:309-796-3460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X, 225X00000X
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
IL0254560006Medicare NSC
IL555640Medicare ID - Type UnspecifiedGROUP BILLING # FOR P.T.
IL555650Medicare ID - Type UnspecifiedGROUP BILLING # FOR O.T.