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General NPI Number Information
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NPI Number | 1518469063
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Entity Type | Organization
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Legal Business Name | REVOLUTION PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 03/01/2018
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Last Update Date | 05/30/2023
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Provider Practice Location Address
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Address Line | 3075 GOODMAN RD E SUITE 7
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City | SOUTHAVEN
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State | MS
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Zip | 38672-6359
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Country | US
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Telephone | 662-349-9288
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Fax | 662-349-9289
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Provider Business Mailing Address
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Address Line | 3075 GOODMAN RD E SUITE 7
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City | SOUTHAVEN
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State | MS
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Zip | 38672-6359
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Country | US
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Telephone | 662-349-9288
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Fax | 662-349-9289
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Authorized Official
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Title or Position | OWNER
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Name | AMY GRAHAM
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Credential | DPT
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Telephone | 662-349-9288
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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