Provider Demographics
NPI:1518469063
Name:REVOLUTION PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:REVOLUTION PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:662-349-9288
Mailing Address - Street 1:3075 GOODMAN RD E SUITE 7
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6359
Mailing Address - Country:US
Mailing Address - Phone:662-349-9288
Mailing Address - Fax:662-349-9289
Practice Address - Street 1:3075 GOODMAN RD E SUITE 7
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6359
Practice Address - Country:US
Practice Address - Phone:662-349-9288
Practice Address - Fax:662-349-9289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-01
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty