Healthcare Provider Details

I. General information

NPI: 1689059917
Provider Name (Legal Business Name): REVIVE PHYSICAL THERAPY AND WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4703 S LAKESHORE DR STE 2
TEMPE AZ
85282
US

IV. Provider business mailing address

4703 S LAKESHORE DR STE 2
TEMPE AZ
85282-7159
US

V. Phone/Fax

Practice location:
  • Phone: 480-718-9493
  • Fax:
Mailing address:
  • Phone: 480-718-9493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number9950
License Number StateAZ

VIII. Authorized Official

Name: DAYNA MONTERREY
Title or Position: OWNE
Credential:
Phone: 480-718-9493