Provider Demographics
NPI:1164766606
Name:REVOLUTION PTWL LLC
Entity Type:Organization
Organization Name:REVOLUTION PTWL LLC
Other - Org Name:REVOLUTION PHYSICAL THERAPY WEIGHT LOSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIESER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-878-8800
Mailing Address - Street 1:845 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 973W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2252
Mailing Address - Country:US
Mailing Address - Phone:312-878-8800
Mailing Address - Fax:312-448-9978
Practice Address - Street 1:845 N MICHIGAN AVE
Practice Address - Street 2:SUITE 973W
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-878-8800
Practice Address - Fax:312-448-9978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-21
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty