Healthcare Provider Details

I. General information

NPI: 1629924675
Provider Name (Legal Business Name): REVIGEN HEALTH AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431376 E 340 RD
BIG CABIN OK
74332-8006
US

IV. Provider business mailing address

518 W WILL ROGERS BLVD
CLAREMORE OK
74017-6823
US

V. Phone/Fax

Practice location:
  • Phone: 918-205-2685
  • Fax:
Mailing address:
  • Phone: 918-630-6485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARA ENYART
Title or Position: OWNER/PROVIDER
Credential: PA-C
Phone: 918-630-6485