MEDICARE: REVOLUTION THERAPY & FITNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	224Z00000X	Occupational Therapy Assistant
2	225200000X	Physical Therapy Assistant
3	225X00000X	Occupational Therapist
4	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427404730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVOLUTION THERAPY & FITNESS LLC

Provider Business Mailing Address
First Line	:	215 BLOSSOM ST
Second Line	:
City	:	GOOSE CREEK
State	:	SC
Zip	:	29445-3516
Country	:	US
Telephone Number	:	843-323-0174
Fax Number	:	888-856-3189

Provider Business Practice Location Address
First Line	:	8626 DORCHESTER RD STE 103
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29420-7328
Country	:	US
Telephone Number	:	843-964-4996
Fax Number	:	888-856-3189

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPY ASSISTANT
Name	:	LLEWELLYN SEAN WORSHAM
Credential	:
Telephone Number	:	843-323-0174

Provider Enumeration Date	:	05/05/2016
Last Update Date	:	08/24/2020

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Directions to “REVOLUTION THERAPY & FITNESS LLC ” Practice Location

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