Provider Demographics
NPI:1194594937
Name:REVOLUS, FLADJY RIVENS
Entity type:Individual
Prefix:
First Name:FLADJY
Middle Name:RIVENS
Last Name:REVOLUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7698 LOWER GATEWAY LOOP UNIT 824
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7198
Mailing Address - Country:US
Mailing Address - Phone:813-464-5276
Mailing Address - Fax:
Practice Address - Street 1:13800 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7401
Practice Address - Country:US
Practice Address - Phone:407-631-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT40641225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist