Provider Demographics
NPI:1922789361
Name:REVIVE PELVIC HEALTH PLLC
Entity Type:Organization
Organization Name:REVIVE PELVIC HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BUSTOS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:906-281-5544
Mailing Address - Street 1:19045 WHITE PINE LN
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-9066
Mailing Address - Country:US
Mailing Address - Phone:906-281-5544
Mailing Address - Fax:
Practice Address - Street 1:47461 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-9016
Practice Address - Country:US
Practice Address - Phone:906-285-6720
Practice Address - Fax:906-254-3554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-28
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy