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General NPI Number Information
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NPI Number | 1689059917
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Entity Type | Organization
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Legal Business Name | REVIVE PHYSICAL THERAPY AND WELLNESS, PLLC
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Dates
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Enumeration Date | 07/28/2015
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Last Update Date | 06/04/2018
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Provider Practice Location Address
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Address Line | 4703 S LAKESHORE DR STE 2
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City | TEMPE
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State | AZ
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Zip | 85282
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Country | US
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Telephone | 480-718-9493
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Fax |
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Provider Business Mailing Address
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Address Line | 4703 S LAKESHORE DR STE 2
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City | TEMPE
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State | AZ
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Zip | 85282-7159
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Country | US
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Telephone | 480-718-9493
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Fax |
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Authorized Official
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Title or Position | OWNE
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Name | DAYNA MONTERREY
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Credential |
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Telephone | 480-718-9493
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 9950
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License Number State | AZ
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