Provider Demographics
NPI:1760993653
Name:RESTORE AND REVITALIZE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:RESTORE AND REVITALIZE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TULSI
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDULA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CLT, CES
Authorized Official - Phone:215-880-7701
Mailing Address - Street 1:3 WINDROW LN
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1777
Mailing Address - Country:US
Mailing Address - Phone:215-880-7701
Mailing Address - Fax:
Practice Address - Street 1:3 WINDROW LN
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1777
Practice Address - Country:US
Practice Address - Phone:215-880-7701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT025052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty