Provider Demographics
NPI:1982102620
Name:REVIVE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:REVIVE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-704-5611
Mailing Address - Street 1:3261 EFFIE RD
Mailing Address - Street 2:
Mailing Address - City:HESTER
Mailing Address - State:LA
Mailing Address - Zip Code:70743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12550 AIRLINE HWY STE 102
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2269
Practice Address - Country:US
Practice Address - Phone:985-703-2412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy