Provider Demographics
NPI:1659785061
Name:REVOLUTIONARY REHAB WELLNESS CORP
Entity Type:Organization
Organization Name:REVOLUTIONARY REHAB WELLNESS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:201-438-4400
Mailing Address - Street 1:138 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:EAST RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07073-1855
Mailing Address - Country:US
Mailing Address - Phone:201-438-4400
Mailing Address - Fax:201-203-1748
Practice Address - Street 1:138 PARK AVE
Practice Address - Street 2:
Practice Address - City:EAST RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07073-1855
Practice Address - Country:US
Practice Address - Phone:201-438-4400
Practice Address - Fax:201-203-1748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00805300261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy