Healthcare Provider Details

I. General information

NPI: 1730795980
Provider Name (Legal Business Name): REVELLE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/10/2022
Certification Date: 09/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5502 PEACHTREE RD STE 100
CHAMBLEE GA
30341-2310
US

IV. Provider business mailing address

5502 PEACHTREE RD STE 100
CHAMBLEE GA
30341-2314
US

V. Phone/Fax

Practice location:
  • Phone: 770-800-2377
  • Fax:
Mailing address:
  • Phone: 478-954-9311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1255745592
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI
# 2
Identifier1588059380
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerNPI
# 3
Identifier1568611986
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI
# 4
Identifier1053651026
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI
# 5
Identifier1225661184
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI
# 6
Identifier1477007342
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI
# 7
Identifier1730598863
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI

VIII. Authorized Official

Name: AMY MEEHAN
Title or Position: PHYSICAL THERAPY, OWNER
Credential: PT, DPT, MTC
Phone: 478-954-9311