Provider Demographics
NPI:1568139269
Name:REVITALIZE 3D
Entity Type:Organization
Organization Name:REVITALIZE 3D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:785-477-2647
Mailing Address - Street 1:1427 S 680 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-5544
Mailing Address - Country:US
Mailing Address - Phone:785-477-2647
Mailing Address - Fax:
Practice Address - Street 1:184 W 400 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2855
Practice Address - Country:US
Practice Address - Phone:785-477-2647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-30
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomicsGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No2251H1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHuman FactorsGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty