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General NPI Number Information
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NPI Number | 1598038119
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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 | 02/13/2012
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Last Update Date | 06/27/2018
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Provider Practice Location Address
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Address Line | 904 S WALKER ST STE B
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City | BURGAW
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State | NC
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Zip | 28425-5008
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Country | US
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Telephone | 910-789-4770
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Fax | 910-672-7622
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Provider Business Mailing Address
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Address Line | PO BOX 1799
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City | BURGAW
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State | NC
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Zip | 28425-1799
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Country | US
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Telephone | 910-789-4770
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Fax | 910-672-7622
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. HORACE VERNON PIGFORD III
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Credential | PT
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Telephone | 910-789-4770
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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 | P12005
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License Number State | NC
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