Provider Demographics
NPI:1215204110
Name:REVIVE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:REVIVE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:RENUKA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, COMT
Authorized Official - Phone:443-364-4495
Mailing Address - Street 1:10300 BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:UNIT #B
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2128
Mailing Address - Country:US
Mailing Address - Phone:443-364-4495
Mailing Address - Fax:
Practice Address - Street 1:10300 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:UNIT #B
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2128
Practice Address - Country:US
Practice Address - Phone:443-364-4495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-20
Last Update Date:2011-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22176261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy