Provider Demographics
NPI:1790411569
Name:REVITALIZE ATHLETICS, PLLC
Entity Type:Organization
Organization Name:REVITALIZE ATHLETICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:626-512-5559
Mailing Address - Street 1:9643 W 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-4755
Mailing Address - Country:US
Mailing Address - Phone:626-512-5559
Mailing Address - Fax:
Practice Address - Street 1:9643 W 14TH AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-4755
Practice Address - Country:US
Practice Address - Phone:626-512-5559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty