Healthcare Provider Details

I. General information

NPI: 1023671625
Provider Name (Legal Business Name): REVERVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 ALASKAN WAY S APT 506
SEATTLE WA
98104-2585
US

IV. Provider business mailing address

114 ALASKA WAY S SUITE 506
SEATTLE WA
98104
US

V. Phone/Fax

Practice location:
  • Phone: 206-487-3391
  • Fax: 866-264-3391
Mailing address:
  • Phone: 206-487-3391
  • Fax: 866-264-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JANELLE GUERRERO
Title or Position: BILLING
Credential:
Phone: 877-669-6927