Basic Information
| Provider Information | |||||||||
| NPI: | 1306476486 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REVITALIZE REHAB AND WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 934 BAY POINTE DR | ||||||||
| Address2: | |||||||||
| City: | FREEBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622432737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185670413 | ||||||||
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| Practice Location | |||||||||
| Address1: | 934 BAY POINTE DR | ||||||||
| Address2: | |||||||||
| City: | FREEBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622432737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185670413 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2020 | ||||||||
| LastUpdateDate: | 01/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAHAN | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6185670413 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 01/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.