MEDICARE: REVIVE REHAB CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1619414687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE REHAB CENTER LLC

Provider Business Mailing Address
First Line	:	2118 S WAYNE RD
Second Line	:
City	:	WESTLAND
State	:	MI
Zip	:	48186-5428
Country	:	US
Telephone Number	:	313-995-6788
Fax Number	:

Provider Business Practice Location Address
First Line	:	2118 S WAYNE RD
Second Line	:
City	:	WESTLAND
State	:	MI
Zip	:	48186-5428
Country	:	US
Telephone Number	:	313-995-6788
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANGIE BAZZI
Credential	:
Telephone Number	:	313-995-6788

Provider Enumeration Date	:	01/27/2017
Last Update Date	:	01/27/2017

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