Healthcare Provider Details

I. General information

NPI: 1215204110
Provider Name (Legal Business Name): REVIVE PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2011
Last Update Date: 11/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 BALTIMORE NATIONAL PIKE UNIT #B
ELLICOTT CITY MD
21042-2128
US

IV. Provider business mailing address

10300 BALTIMORE NATIONAL PIKE UNIT #B
ELLICOTT CITY MD
21042-2128
US

V. Phone/Fax

Practice location:
  • Phone: 443-364-4495
  • Fax:
Mailing address:
  • Phone: 443-364-4495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number22176
License Number StateMD

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. RENUKA JAIN
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: DPT, COMT
Phone: 443-364-4495