# REVIVE PHYSICAL THERAPY LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1457819534
- **Authorized official:** KENTON MARC BROOK (PRESIDENT)
- **Authorized official phone:** (503) 691-2723

## Contact information

- **Practice address:** 18019 SW LOWER BOONES FERRY RD, PORTLAND, OR 97224
- **Practice address phone:** (503) 691-2723
- **Practice address fax:** (503) 692-5406
- **Mailing address:** 18019 SW LOWER BOONES FERRY RD, PORTLAND, OR 97224
- **Mailing address phone:** (503) 691-2723
- **Mailing address fax:** (503) 692-5406

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | NULL | Yes |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | Yes |

## Other

- **Enumeration date:** 03/07/2019
- **Last updated:** 03/07/2019