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General NPI Number Information
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NPI Number | 1518526953
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Entity Type | Organization
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Legal Business Name | REVIVAL PHYSICAL THERAPY, LLC
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Dates
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Enumeration Date | 06/10/2019
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Last Update Date | 06/10/2019
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Provider Practice Location Address
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Address Line | 4116 SWINDON CT
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City | CHARLOTTE
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State | NC
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Zip | 28215-5355
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Country | US
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Telephone | 980-230-3276
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Fax |
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Provider Business Mailing Address
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Address Line | 4116 SWINDON CT
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City | CHARLOTTE
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State | NC
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Zip | 28215-5355
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Country | US
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Telephone | 980-230-3276
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MITCHELL SAMONTE MONTEMAYOR
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Credential | PT
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Telephone | 980-276-3066
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081H0002X
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Taxonomy Name | Hospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State |
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