Provider Demographics
NPI:1992927180
Name:GAULEY RIVER PHYSICAL THERAPY AND REHABILITATION, LLC
Entity type:Organization
Organization Name:GAULEY RIVER PHYSICAL THERAPY AND REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:304-872-0490
Mailing Address - Street 1:704 PROFESSIONAL PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-2000
Mailing Address - Country:US
Mailing Address - Phone:304-872-0490
Mailing Address - Fax:304-872-0492
Practice Address - Street 1:704 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-2000
Practice Address - Country:US
Practice Address - Phone:304-872-0490
Practice Address - Fax:304-872-0492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0157391000Medicaid
WV0157391000Medicaid