Provider Demographics
NPI:1477911329
Name:REVITALIFE THERAPY LLC
Entity Type:Organization
Organization Name:REVITALIFE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-661-3840
Mailing Address - Street 1:212 BILLETTS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27921-7505
Mailing Address - Country:US
Mailing Address - Phone:646-661-3840
Mailing Address - Fax:252-377-4231
Practice Address - Street 1:212 BILLETTS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NC
Practice Address - Zip Code:27921-7505
Practice Address - Country:US
Practice Address - Phone:646-661-3840
Practice Address - Fax:252-377-4231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty