1063741676 NPI number — REVIVAL PHYSICAL THERAPY & REHABILITATION SERVICES, PC

Table of content: (NPI 1063741676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063741676 NPI number — REVIVAL PHYSICAL THERAPY & REHABILITATION SERVICES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVAL PHYSICAL THERAPY & REHABILITATION SERVICES, PC
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:
1063741676
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 GIBSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE PLAINS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10607-2030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-358-5483
Provider Business Mailing Address Fax Number:
914-358-5484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3706 THIRD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10456-2145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-591-4136
Provider Business Practice Location Address Fax Number:
347-726-3036
Provider Enumeration Date:
12/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GBOTOSHO
Authorized Official First Name:
OLATUNJI
Authorized Official Middle Name:
Authorized Official Title or Position:
PT
Authorized Official Telephone Number:
914-948-7641

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X , with the licence number: 017179 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com