Provider Demographics
NPI:1821596586
Name:REVOLUTION PHYSICAL THERAPY NYC PLLC
Entity Type:Organization
Organization Name:REVOLUTION PHYSICAL THERAPY NYC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LORAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTOINE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:917-363-6433
Mailing Address - Street 1:893 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-6654
Mailing Address - Country:US
Mailing Address - Phone:917-922-2682
Mailing Address - Fax:
Practice Address - Street 1:165 BROADWAY FL 23
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-1404
Practice Address - Country:US
Practice Address - Phone:917-922-2682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029251225100000X
NY016510225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty