Provider Demographics
NPI:1457618902
Name:REVITA REHAB NORTH LLC
Entity Type:Organization
Organization Name:REVITA REHAB NORTH LLC
Other - Org Name:REVITA REHAB NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ELMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-489-4249
Mailing Address - Street 1:203 E DALKE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-8112
Mailing Address - Country:US
Mailing Address - Phone:509-489-4249
Mailing Address - Fax:509-483-8338
Practice Address - Street 1:203 E DALKE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-8112
Practice Address - Country:US
Practice Address - Phone:509-489-4249
Practice Address - Fax:509-483-8338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT225100000X
WA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty