1922353143 NPI number — REVIVE REHAB SERVICES LLC

Table of content: (NPI 1922353143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922353143 NPI number — REVIVE REHAB SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVE REHAB SERVICES LLC
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:
1922353143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1015 YORKSHIRE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREINIGSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18031-1544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-891-0608
Provider Business Mailing Address Fax Number:
484-283-2232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
623 W UNION BLVD STE 1B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BETHLEHEM
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18018-3708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-891-0608
Provider Business Practice Location Address Fax Number:
484-283-2232
Provider Enumeration Date:
07/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JASIM
Authorized Official First Name:
MUHAMMAD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
484-891-0608

Provider Taxonomy Codes

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

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

  • Identifier: 102786220 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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