Provider Demographics
NPI:1992277107
Name:REVOLUTION PHYSICAL THERAPY
Entity type:Organization
Organization Name:REVOLUTION PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-521-4743
Mailing Address - Street 1:195 COMMERCIAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-5234
Mailing Address - Country:US
Mailing Address - Phone:606-657-5111
Mailing Address - Fax:606-657-2354
Practice Address - Street 1:195 COMMERCIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-5234
Practice Address - Country:US
Practice Address - Phone:606-657-5111
Practice Address - Fax:606-657-2354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-28
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100592450Medicaid