Provider Demographics
NPI:1245547652
Name:REVOLUTION REHAB
Entity type:Organization
Organization Name:REVOLUTION REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MINICOZZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-531-9914
Mailing Address - Street 1:5871 GLENRIDGE DR NE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5871 GLENRIDGE DR NE
Practice Address - Street 2:SUITE 115
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-5375
Practice Address - Country:US
Practice Address - Phone:404-531-9914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy