Provider Demographics
NPI:1114371275
Name:MOPURU, REVANTH
Entity Type:Individual
Prefix:
First Name:REVANTH
Middle Name:
Last Name:MOPURU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6140 HARDY AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1589
Mailing Address - Country:US
Mailing Address - Phone:573-639-0181
Mailing Address - Fax:
Practice Address - Street 1:2815 NORTHWIND DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5003
Practice Address - Country:US
Practice Address - Phone:517-332-0817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist