1023654563 NPI number — REVAMP PHYSICAL THERAPY REHAB PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023654563 NPI number — REVAMP PHYSICAL THERAPY REHAB PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVAMP PHYSICAL THERAPY REHAB PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023654563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 LA BONNE VIE DR APT G
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST PATCHOGUE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11772-4398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-482-2754
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
285 COMMACK RD STE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COMMACK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11725-3403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-482-2754
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2019

Additional Information

Authorized Official

Authorized Official Last Name:
VOSKAMP
Authorized Official First Name:
SYLVERA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
631-482-2754

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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