Provider Demographics
NPI:1730943424
Name:REVIVAL PHYSICAL THERAPY AND WELLNESS
Entity type:Organization
Organization Name:REVIVAL PHYSICAL THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:952-220-3105
Mailing Address - Street 1:11630 IDAHO AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-2894
Mailing Address - Country:US
Mailing Address - Phone:952-220-3105
Mailing Address - Fax:
Practice Address - Street 1:4123 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-1808
Practice Address - Country:US
Practice Address - Phone:612-605-7594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy