Provider Demographics
NPI:1922353143
Name:REVIVE REHAB SERVICES LLC
Entity Type:Organization
Organization Name:REVIVE REHAB SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:JASIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-891-0608
Mailing Address - Street 1:1015 YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BREINIGSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18031-1544
Mailing Address - Country:US
Mailing Address - Phone:484-891-0608
Mailing Address - Fax:484-283-2232
Practice Address - Street 1:623 W UNION BLVD STE 1B
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-3708
Practice Address - Country:US
Practice Address - Phone:484-891-0608
Practice Address - Fax:484-283-2232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-14
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102786220Medicaid