Provider Demographics
NPI:1598215170
Name:REVOLUTION SPORT & SPINE THERAPY LLC
Entity Type:Organization
Organization Name:REVOLUTION SPORT & SPINE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:907-420-0836
Mailing Address - Street 1:35249 KENAI SPUR HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7623
Mailing Address - Country:US
Mailing Address - Phone:907-420-0836
Mailing Address - Fax:907-420-0837
Practice Address - Street 1:35249 KENAI SPUR HWY
Practice Address - Street 2:SUITE C
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7623
Practice Address - Country:US
Practice Address - Phone:541-913-3089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-07
Last Update Date:2017-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10427832251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty