Provider Demographics
NPI:1346750601
Name:REVITALIZE REHAB CLUB
Entity Type:Organization
Organization Name:REVITALIZE REHAB CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANH
Authorized Official - Middle Name:
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:PT DPT OCS SCS
Authorized Official - Phone:562-548-0876
Mailing Address - Street 1:3646 LONG BEACH BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-6025
Mailing Address - Country:US
Mailing Address - Phone:562-548-0876
Mailing Address - Fax:
Practice Address - Street 1:3646 LONG BEACH BLVD STE 106
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-6025
Practice Address - Country:US
Practice Address - Phone:562-548-0876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303402251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty