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General NPI Number Information
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NPI Number | 1730943424
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Entity Type | Organization
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Legal Business Name | REVIVAL PHYSICAL THERAPY AND WELLNESS
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Dates
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Enumeration Date | 02/12/2024
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Last Update Date | 02/12/2024
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Provider Practice Location Address
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Address Line | 4123 W BROADWAY AVE
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City | ROBBINSDALE
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State | MN
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Zip | 55422-1808
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Country | US
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Telephone | 612-605-7594
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Fax |
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Provider Business Mailing Address
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Address Line | 11630 IDAHO AVE N
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City | CHAMPLIN
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State | MN
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Zip | 55316-2894
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Country | US
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Telephone | 952-220-3105
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Fax |
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Authorized Official
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Title or Position | CO-OWNER, PHYSICAL THERAPIST
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Name | DR. BENJAMIN BRITTON
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Credential | DPT
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Telephone | 952-220-3105
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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 |
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License Number State |
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