Provider Demographics
NPI:1518526953
Name:REVIVAL PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:REVIVAL PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:SAMONTE
Authorized Official - Last Name:MONTEMAYOR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:980-276-3066
Mailing Address - Street 1:4116 SWINDON CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-5355
Mailing Address - Country:US
Mailing Address - Phone:980-230-3276
Mailing Address - Fax:
Practice Address - Street 1:4116 SWINDON CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-5355
Practice Address - Country:US
Practice Address - Phone:980-230-3276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative MedicineGroup - Single Specialty