Healthcare Provider Details

I. General information

NPI: 1841034535
Provider Name (Legal Business Name): REVIVE THERAPY AND PERFORMANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 E 2ND ST
MOUNDRIDGE KS
67107-7164
US

IV. Provider business mailing address

324 E 2ND ST
MOUNDRIDGE KS
67107-7164
US

V. Phone/Fax

Practice location:
  • Phone: 620-345-7400
  • Fax: 620-345-7410
Mailing address:
  • Phone: 620-345-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code225XR0403X
TaxonomyDriving and Community Mobility Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JESSANNA GRAYCE SCHUMANN
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 620-217-0583