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General NPI Number Information
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NPI Number | 1578265260
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Entity Type | Organization
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Legal Business Name | REVIVE PHYSIOTHERAPY AND WELLNESS
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Dates
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Enumeration Date | 03/20/2023
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Last Update Date | 03/20/2023
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Provider Practice Location Address
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Address Line | 4125 LAUREL HILLS RD
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City | RALEIGH
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State | NC
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Zip | 27612-5411
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Country | US
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Telephone | 919-670-1310
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Fax |
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Provider Business Mailing Address
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Address Line | 4125 LAUREL HILLS RD
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City | RALEIGH
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State | NC
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Zip | 27612-5411
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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 | OWNER & PHYSICAL THERAPIST
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Name | DR. KELLY CHILDRESS OSCHWALD
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Credential | PT, DPT, COMT
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Telephone | 919-670-1310
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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 |
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License Number State |
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Taxonomy #2
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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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