1720471345 NPI number — REVOLUTION REHABILITATION AND SPORTS PERFORAMANCE LLC

Table of content: (NPI 1720471345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720471345 NPI number — REVOLUTION REHABILITATION AND SPORTS PERFORAMANCE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVOLUTION REHABILITATION AND SPORTS PERFORAMANCE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
REVOLUTION REHAB
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720471345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2653 CEDAR ELM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODENTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21113-2905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-848-2284
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 RUSSELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21230-2622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-848-2284
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BOURDEAU
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
SEAN
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
301-848-2284

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  24069 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2000X , with the licence number: 23944 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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