Provider Demographics
NPI:1598817165
Name:BECKETT RIDGE PHYSICAL THERAPY
Entity type:Organization
Organization Name:BECKETT RIDGE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLUSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:513-874-2778
Mailing Address - Street 1:4934 WUNNENBERG WAY
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-4985
Mailing Address - Country:US
Mailing Address - Phone:513-874-2778
Mailing Address - Fax:513-881-2252
Practice Address - Street 1:4934 WUNNENBERG WY
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069
Practice Address - Country:US
Practice Address - Phone:513-874-2778
Practice Address - Fax:513-881-2252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07586225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2208962Medicaid