Provider Demographics
NPI:1841243359
Name:REVIVAL PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:REVIVAL PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/ OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINZY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:904-264-3005
Mailing Address - Street 1:2301 PARK AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5565
Mailing Address - Country:US
Mailing Address - Phone:904-264-3005
Mailing Address - Fax:904-264-0012
Practice Address - Street 1:2301 PARK AVE STE 1
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5565
Practice Address - Country:US
Practice Address - Phone:904-264-3005
Practice Address - Fax:904-264-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884338400Medicaid
FL686521Medicare ID - Type Unspecified