Provider Demographics
NPI:1104361898
Name:REVREHAB, LTD.
Entity type:Organization
Organization Name:REVREHAB, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SKOTNICKI
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:847-977-7188
Mailing Address - Street 1:1250 GOLDFINCH LN
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-6410
Mailing Address - Country:US
Mailing Address - Phone:847-977-7188
Mailing Address - Fax:
Practice Address - Street 1:23410 W APOLLO CT
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-9638
Practice Address - Country:US
Practice Address - Phone:847-856-9014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013436261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy