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General NPI Number Information
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NPI Number | 1972133817
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Entity Type | Organization
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Legal Business Name | REVIVE PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 01/20/2020
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Last Update Date | 12/18/2020
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Provider Practice Location Address
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Address Line | 36180 DOMINION CIR
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City | STERLING HEIGHTS
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State | MI
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Zip | 48310-7456
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Country | US
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Telephone | 810-555-5555
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Fax |
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Provider Business Mailing Address
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Address Line | 1665 BLOOMFIELD PLACE DR APT 422
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City | BLOOMFIELD HILLS
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State | MI
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Zip | 48302-3513
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TRE WILLIAMS
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Credential |
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Telephone | 810-555-5555
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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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