Provider Demographics
NPI:1063741676
Name:REVIVAL PHYSICAL THERAPY & REHABILITATION SERVICES, PC
Entity type:Organization
Organization Name:REVIVAL PHYSICAL THERAPY & REHABILITATION SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:OLATUNJI
Authorized Official - Middle Name:
Authorized Official - Last Name:GBOTOSHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-948-7641
Mailing Address - Street 1:102 GIBSON AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10607-2030
Mailing Address - Country:US
Mailing Address - Phone:914-358-5483
Mailing Address - Fax:914-358-5484
Practice Address - Street 1:3706 THIRD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-2145
Practice Address - Country:US
Practice Address - Phone:347-591-4136
Practice Address - Fax:347-726-3036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NY017179261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6328810002Medicare NSC