Provider Demographics
NPI:1508130345
Name:REVIVE HEALTH & WELLNESS
Entity Type:Organization
Organization Name:REVIVE HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MPT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-387-7783
Mailing Address - Street 1:4213 STONE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-9233
Mailing Address - Country:US
Mailing Address - Phone:502-387-7783
Mailing Address - Fax:812-941-0198
Practice Address - Street 1:3541 PAOLI PIKE
Practice Address - Street 2:
Practice Address - City:FLOYDS KNOBS
Practice Address - State:IN
Practice Address - Zip Code:47119-9751
Practice Address - Country:US
Practice Address - Phone:502-387-7783
Practice Address - Fax:812-941-0198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004967A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty