MEDICARE: REVIVE PHYSICAL THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist
2	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1437810546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	2151 45TH STREET
Second Line	:	SUITE 104
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-2028
Country	:	US
Telephone Number	:	561-247-7337
Fax Number	:	561-727-8908

Provider Business Practice Location Address
First Line	:	2151 45TH STREET
Second Line	:	SUITE 104
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-2028
Country	:	US
Telephone Number	:	561-247-7337
Fax Number	:	561-727-8908

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. BLAIRE STANLEY
Credential	:	M.S./CCC-SLP
Telephone Number	:	561-247-7337

Provider Enumeration Date	:	01/02/2022
Last Update Date	:	06/26/2023

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Directions to “REVIVE PHYSICAL THERAPY LLC ” Practice Location

Language	Start Address	Practice Location

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