Healthcare Provider Details

I. General information

NPI: 1487573879
Provider Name (Legal Business Name): REVIVE HEALTH SPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N MAIN AVE
BOLIVAR MO
65613-1517
US

IV. Provider business mailing address

107 N MAIN AVE
BOLIVAR MO
65613-1517
US

V. Phone/Fax

Practice location:
  • Phone: 417-680-7060
  • Fax: 800-828-7117
Mailing address:
  • Phone: 417-680-7060
  • Fax: 800-828-7117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHELBY BAILEY
Title or Position: OWNER
Credential: NP
Phone: 417-298-6908