=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992076368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REV SPORTS REHAB & ATHLETIC DEVELOPMENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2012
-----------------------------------------------------
Last Update Date | 01/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 290 EXECUTIVE DR SUITE #103
-----------------------------------------------------
City | CRANBERRY TWP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16066-6436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-612-4747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 290 EXECUTIVE DR UNIT #103
-----------------------------------------------------
City | CRANBERRY TWP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16066-6436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-612-4747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPORTS MEDICINE PHYSICAL THERAPIST
-----------------------------------------------------
Name | AIMEE SLATTERY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 724-612-4747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT021258
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------