Provider Demographics
NPI:1689266009
Name:REVIVE PELVIC HEALTH & PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:REVIVE PELVIC HEALTH & PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-953-6876
Mailing Address - Street 1:107 VICTORIA LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4031
Mailing Address - Country:US
Mailing Address - Phone:601-953-6876
Mailing Address - Fax:
Practice Address - Street 1:107 VICTORIA LN
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4031
Practice Address - Country:US
Practice Address - Phone:601-953-6876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center