Provider Demographics
NPI:1437812484
Name:REVIVE ORTHOPEDIC AND SPINAL THERAPY
Entity Type:Organization
Organization Name:REVIVE ORTHOPEDIC AND SPINAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TAX ID OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRAHAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:KUTA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:440-357-1717
Mailing Address - Street 1:7545 FREDLE DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9406
Mailing Address - Country:US
Mailing Address - Phone:440-357-1717
Mailing Address - Fax:440-357-5252
Practice Address - Street 1:7545 FREDLE DR
Practice Address - Street 2:
Practice Address - City:CONCORD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44077-9406
Practice Address - Country:US
Practice Address - Phone:440-357-1717
Practice Address - Fax:440-357-5252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty