Provider Demographics
NPI:1467179663
Name:PT REVOLUTION PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:PT REVOLUTION PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-307-3316
Mailing Address - Street 1:2038 LAKE TAHOE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6499
Mailing Address - Country:US
Mailing Address - Phone:530-208-9910
Mailing Address - Fax:530-285-2001
Practice Address - Street 1:2038 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6499
Practice Address - Country:US
Practice Address - Phone:530-208-9910
Practice Address - Fax:530-285-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-27
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy