Provider Demographics
NPI:1568857118
Name:REVERT LLC
Entity Type:Organization
Organization Name:REVERT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARON
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DUFFY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS
Authorized Official - Phone:774-392-0612
Mailing Address - Street 1:111 TWO PONDS RD
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02540-2221
Mailing Address - Country:US
Mailing Address - Phone:508-356-3952
Mailing Address - Fax:508-437-2597
Practice Address - Street 1:634 N FALMOUTH HWY UNIT 10
Practice Address - Street 2:
Practice Address - City:NORTH FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02556
Practice Address - Country:US
Practice Address - Phone:508-356-3952
Practice Address - Fax:508-437-2597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy