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General NPI Number Information
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NPI Number | 1720471345
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Entity Type | Organization
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Legal Business Name | REVOLUTION REHABILITATION AND SPORTS PERFORAMANCE LLC
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Dates
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Enumeration Date | 03/05/2015
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Last Update Date | 04/02/2015
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Provider Practice Location Address
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Address Line | 1100 RUSSELL ST
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City | BALTIMORE
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State | MD
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Zip | 21230-2622
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Country | US
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Telephone | 301-848-2284
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Fax |
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Provider Business Mailing Address
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Address Line | 2653 CEDAR ELM DR
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City | ODENTON
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State | MD
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Zip | 21113-2905
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Country | US
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Telephone | 301-848-2284
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | DR. MATTHEW SEAN BOURDEAU
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Credential | DPT
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Telephone | 301-848-2284
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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 | 23944
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 24069
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License Number State | MD
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