Provider Demographics
NPI:1689059917
Name:REVIVE PHYSICAL THERAPY AND WELLNESS, PLLC
Entity Type:Organization
Organization Name:REVIVE PHYSICAL THERAPY AND WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNE
Authorized Official - Prefix:
Authorized Official - First Name:DAYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTERREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-718-9493
Mailing Address - Street 1:4703 S LAKESHORE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7159
Mailing Address - Country:US
Mailing Address - Phone:480-718-9493
Mailing Address - Fax:
Practice Address - Street 1:4703 S LAKESHORE DR STE 2
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-718-9493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9950261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ734323Medicaid
AZZ155652Medicare PIN