Healthcare Provider Details

I. General information

NPI: 1861153090
Provider Name (Legal Business Name): REVITALIZE PHYSICAL THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 BROADWAY
MEDORA ND
58645
US

IV. Provider business mailing address

425 BROADWAY
MEDORA ND
58645
US

V. Phone/Fax

Practice location:
  • Phone: 701-872-6724
  • Fax: 701-353-2073
Mailing address:
  • Phone: 701-872-6724
  • Fax: 701-353-2073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: HANNAH LEE FREIBOTH
Title or Position: OWNER
Credential: PT, DPT
Phone: 701-872-6724