Provider Demographics
NPI:1598229155
Name:NEUROREV PLLC
Entity Type:Organization
Organization Name:NEUROREV PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-243-6822
Mailing Address - Street 1:520 N MARKET PLACE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-4904
Mailing Address - Country:US
Mailing Address - Phone:801-243-6822
Mailing Address - Fax:
Practice Address - Street 1:520 N MARKET PLACE DR STE 200
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-4904
Practice Address - Country:US
Practice Address - Phone:801-243-6822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy