Healthcare Provider Details

I. General information

NPI: 1538721907
Provider Name (Legal Business Name): REVOLUTION SPORTS AND PERFORMANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27774 AUTUMN BREEZE CIR
WESLEY CHAPEL FL
33544-7839
US

IV. Provider business mailing address

27774 AUTUMN BREEZE CIR
WESLEY CHAPEL FL
33544-7839
US

V. Phone/Fax

Practice location:
  • Phone: 813-838-2510
  • Fax:
Mailing address:
  • Phone: 813-838-2510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW DAVID BLEVINS
Title or Position: CEO/OWNER
Credential: DPT
Phone: 813-838-2510