Healthcare Provider Details

I. General information

NPI: 1932059631
Provider Name (Legal Business Name): REVIVE PERFORMANCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2026
Last Update Date: 02/02/2026
Certification Date: 02/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 W HEFNER RD
OKLAHOMA CITY OK
73120-5060
US

IV. Provider business mailing address

5012 SW 129TH CT
OKLAHOMA CITY OK
73173-8882
US

V. Phone/Fax

Practice location:
  • Phone: 405-237-5941
  • Fax: 405-237-5941
Mailing address:
  • Phone: 405-237-5941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN CLARK
Title or Position: OWNER, ATHLETIC TRAINER
Credential: LAT, ATC
Phone: 405-778-4088