Provider Demographics
NPI:1700046224
Name:UPSCALE REVITALAZATION COMMUNITY
Entity Type:Organization
Organization Name:UPSCALE REVITALAZATION COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RIVERS
Authorized Official - Middle Name:RENARD
Authorized Official - Last Name:GLOVER
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:832-798-6878
Mailing Address - Street 1:869 DULLES AVE STE D
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-5754
Mailing Address - Country:US
Mailing Address - Phone:832-798-6878
Mailing Address - Fax:
Practice Address - Street 1:869 DULLES AVE STE D
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-5754
Practice Address - Country:US
Practice Address - Phone:832-798-6878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty