Provider Demographics
NPI:1669277919
Name:REVIVE CARE PT AND WELLNESS CENTER
Entity type:Organization
Organization Name:REVIVE CARE PT AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:NUEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-765-0038
Mailing Address - Street 1:2147 W 96TH AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2034
Mailing Address - Country:US
Mailing Address - Phone:219-765-0038
Mailing Address - Fax:
Practice Address - Street 1:2147 W 96TH AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2034
Practice Address - Country:US
Practice Address - Phone:219-765-0038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty