Provider Demographics
NPI:1336803030
Name:REVIVED MOBILITY LLC
Entity type:Organization
Organization Name:REVIVED MOBILITY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-800-9226
Mailing Address - Street 1:2561 W SELTICE WAY
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-8093
Mailing Address - Country:US
Mailing Address - Phone:208-981-0132
Mailing Address - Fax:
Practice Address - Street 1:2561 W SELTICE WAY
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-8093
Practice Address - Country:US
Practice Address - Phone:208-981-0132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-28
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty