Provider Demographics
NPI:1811281447
Name:REVITALIZAING OUT-PATIENT REHABILITATION FACILITY
Entity type:Organization
Organization Name:REVITALIZAING OUT-PATIENT REHABILITATION FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:FLORIDASTEANE
Authorized Official - Middle Name:
Authorized Official - Last Name:IVORY
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:832-418-2978
Mailing Address - Street 1:10203 FINCHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77036-8606
Mailing Address - Country:US
Mailing Address - Phone:832-418-2978
Mailing Address - Fax:713-728-8655
Practice Address - Street 1:10203 FINCHWOOD LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036-8606
Practice Address - Country:US
Practice Address - Phone:832-418-2978
Practice Address - Fax:713-728-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty