Provider Demographics
NPI:1720471345
Name:REVOLUTION REHABILITATION AND SPORTS PERFORAMANCE LLC
Entity Type:Organization
Organization Name:REVOLUTION REHABILITATION AND SPORTS PERFORAMANCE LLC
Other - Org Name:REVOLUTION REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:BOURDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:301-848-2284
Mailing Address - Street 1:2653 CEDAR ELM DR
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-2905
Mailing Address - Country:US
Mailing Address - Phone:301-848-2284
Mailing Address - Fax:
Practice Address - Street 1:1100 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-2622
Practice Address - Country:US
Practice Address - Phone:301-848-2284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24069261QP2000X
MD23944261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy