Provider Demographics
NPI:1679274252
Name:REVITALIFE PHYSICAL THERAPY AND WELLNESS LLC
Entity Type:Organization
Organization Name:REVITALIFE PHYSICAL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUPAL
Authorized Official - Middle Name:SHRIRAJ
Authorized Official - Last Name:RAVAL
Authorized Official - Suffix:
Authorized Official - Credentials:PT DPT
Authorized Official - Phone:832-548-0080
Mailing Address - Street 1:1007 EVANDALE LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-5309
Mailing Address - Country:US
Mailing Address - Phone:832-548-0080
Mailing Address - Fax:
Practice Address - Street 1:1007 EVANDALE LN
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-5309
Practice Address - Country:US
Practice Address - Phone:832-548-0080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty