Provider Demographics
NPI:1326818386
Name:REVAMP PERFORMANCE AND RECOVERY, LLC
Entity Type:Organization
Organization Name:REVAMP PERFORMANCE AND RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:LEQUAN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:904-701-3310
Mailing Address - Street 1:12220 ATLANTIC BLVD STE 130
Mailing Address - Street 2:#1285
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5826
Mailing Address - Country:US
Mailing Address - Phone:904-444-7610
Mailing Address - Fax:
Practice Address - Street 1:12220 ATLANTIC BLVD STE 130
Practice Address - Street 2:#1285
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-5826
Practice Address - Country:US
Practice Address - Phone:904-444-7610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-02
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty