Healthcare Provider Details

I. General information

NPI: 1063741676
Provider Name (Legal Business Name): REVIVAL PHYSICAL THERAPY & REHABILITATION SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3706 THIRD AVE
BRONX NY
10456-2145
US

IV. Provider business mailing address

102 GIBSON AVE
WHITE PLAINS NY
10607-2030
US

V. Phone/Fax

Practice location:
  • Phone: 347-591-4136
  • Fax: 347-726-3036
Mailing address:
  • Phone: 914-358-5483
  • Fax: 914-358-5484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number017179
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: OLATUNJI GBOTOSHO
Title or Position: PT
Credential:
Phone: 914-948-7641