Provider Demographics
NPI:1841231214
Name:GRAND RIVER PHYSICAL THERAPY & SPORTS MEDICINE, INC
Entity Type:Organization
Organization Name:GRAND RIVER PHYSICAL THERAPY & SPORTS MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:III
Authorized Official - Credentials:MS, PT, ATC
Authorized Official - Phone:660-726-5762
Mailing Address - Street 1:203 S POLK ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:MO
Mailing Address - Zip Code:64402-1618
Mailing Address - Country:US
Mailing Address - Phone:660-726-5762
Mailing Address - Fax:660-726-5764
Practice Address - Street 1:203 S POLK ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:MO
Practice Address - Zip Code:64402-1618
Practice Address - Country:US
Practice Address - Phone:660-726-5762
Practice Address - Fax:660-726-5764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104902225100000X, 2251S0007X
MO1068622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10001794500OtherCOMMUNITY HL PLAN PROV #
MO35391014OtherBC/BS GROUP BILLING NUMBE
MO10001794500OtherCOMMUNITY HL PLAN PROV #