Provider Demographics
NPI:1598038119
Name:REVIVE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:REVIVE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:PIGFORD
Authorized Official - Suffix:III
Authorized Official - Credentials:PT
Authorized Official - Phone:910-789-4770
Mailing Address - Street 1:PO BOX 1799
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-1799
Mailing Address - Country:US
Mailing Address - Phone:910-789-4770
Mailing Address - Fax:910-672-7622
Practice Address - Street 1:904 S WALKER ST STE B
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425-5008
Practice Address - Country:US
Practice Address - Phone:910-789-4770
Practice Address - Fax:910-672-7622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-13
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP12005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty