Provider Demographics
NPI:1902370661
Name:RIVER CITY REHABILITATION
Entity Type:Organization
Organization Name:RIVER CITY REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTA
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOMINO
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:662-335-8332
Mailing Address - Street 1:1707 SOUTH COLORADO SUITE A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703
Mailing Address - Country:US
Mailing Address - Phone:662-335-8332
Mailing Address - Fax:662-335-8852
Practice Address - Street 1:1707 SOUTH COLORADO SUITE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703
Practice Address - Country:US
Practice Address - Phone:662-335-8332
Practice Address - Fax:662-335-8852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015486Medicaid