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General NPI Number Information
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NPI Number | 1598215170
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Entity Type | Organization
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Legal Business Name | REVOLUTION SPORT & SPINE THERAPY LLC
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Dates
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Enumeration Date | 10/07/2016
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Last Update Date | 06/10/2017
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Provider Practice Location Address
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Address Line | 35249 KENAI SPUR HWY SUITE C
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City | SOLDOTNA
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State | AK
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Zip | 99669-7623
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Country | US
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Telephone | 541-913-3089
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Fax |
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Provider Business Mailing Address
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Address Line | 35249 KENAI SPUR HWY SUITE C
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City | SOLDOTNA
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State | AK
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Zip | 99669-7623
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Country | US
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Telephone | 907-420-0836
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Fax | 907-420-0837
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Authorized Official
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Title or Position | CEO
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Name | MARK CUNNINGHAM
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Credential | PT
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Telephone | 907-420-0836
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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 | 1042783
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License Number State | AK
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