=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982102620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2018
-----------------------------------------------------
Last Update Date | 01/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12550 AIRLINE HWY STE 102
-----------------------------------------------------
City | GONZALES
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70737-2269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-703-2412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3261 EFFIE RD
-----------------------------------------------------
City | HESTER
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | TANYA BROUSSARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 337-704-5611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------