Healthcare Provider Details

I. General information

NPI: 1275318495
Provider Name (Legal Business Name): REVAMP REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 04/13/2024
Certification Date: 04/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 SW 22ND PL STE 100
OCALA FL
34471-7759
US

IV. Provider business mailing address

1522 W 23RD ST
HOUSTON TX
77008-1509
US

V. Phone/Fax

Practice location:
  • Phone: 352-620-5211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. EKENE AJUFO
Title or Position: OWNER
Credential: M.D
Phone: 352-620-5211