Provider Demographics
NPI:1831147297
Name:COUNTRY ROADS PHYSICAL THERAPY AND REHABILITATION
Entity Type:Organization
Organization Name:COUNTRY ROADS PHYSICAL THERAPY AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FALKENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:304-363-0050
Mailing Address - Street 1:1509 FAIRMONT AVENUE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1346
Mailing Address - Country:US
Mailing Address - Phone:304-363-0050
Mailing Address - Fax:304-363-0048
Practice Address - Street 1:1509 FAIRMONT AVENUE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1346
Practice Address - Country:US
Practice Address - Phone:304-363-0050
Practice Address - Fax:304-363-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVCO9375661Medicare PIN