Provider Demographics
NPI:1124116173
Name:RIVERSIDE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:RIVERSIDE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMBIOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:740-886-5555
Mailing Address - Street 1:96 TOWNSHIP ROAD 369
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PROCTORVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45669-9133
Mailing Address - Country:US
Mailing Address - Phone:740-886-5555
Mailing Address - Fax:
Practice Address - Street 1:96 TOWNSHIP ROAD 369
Practice Address - Street 2:SUITE 104
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-9133
Practice Address - Country:US
Practice Address - Phone:740-886-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-1007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9359321Medicare PIN