Provider Demographics
NPI:1578813994
Name:REVOLUTIONARY PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:REVOLUTIONARY PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-667-6971
Mailing Address - Street 1:60 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE FERRY
Mailing Address - State:NJ
Mailing Address - Zip Code:07643-1535
Mailing Address - Country:US
Mailing Address - Phone:201-667-6971
Mailing Address - Fax:
Practice Address - Street 1:60 GARDEN ST
Practice Address - Street 2:
Practice Address - City:LITTLE FERRY
Practice Address - State:NJ
Practice Address - Zip Code:07643-1535
Practice Address - Country:US
Practice Address - Phone:201-667-6971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00805300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA00805300OtherPHYSICAL THERAPY LICENSE