Healthcare Provider Details

I. General information

NPI: 1992076368
Provider Name (Legal Business Name): REV SPORTS REHAB & ATHLETIC DEVELOPMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 EXECUTIVE DR SUITE #103
CRANBERRY TWP PA
16066-6436
US

IV. Provider business mailing address

290 EXECUTIVE DR UNIT #103
CRANBERRY TWP PA
16066-6436
US

V. Phone/Fax

Practice location:
  • Phone: 724-612-4747
  • Fax:
Mailing address:
  • Phone: 724-612-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT021258
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: AIMEE SLATTERY
Title or Position: SPORTS MEDICINE PHYSICAL THERAPIST
Credential:
Phone: 724-612-4747