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General NPI Number Information
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NPI Number | 1548702079
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Entity Type | Organization
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Legal Business Name | REVIVE PHYSICAL THERAPY
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Dates
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Enumeration Date | 11/15/2016
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Last Update Date | 11/15/2016
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Provider Practice Location Address
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Address Line | 1330A ROCKLAND AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10314-4944
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Country | US
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Telephone | 718-619-2259
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Fax |
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Provider Business Mailing Address
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Address Line | 112 BIDWELL AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10314-3177
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. TORY BADALAMENTI
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Credential | PT
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Telephone | 718-619-2259
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 17990
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License Number State | NY
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