Healthcare Provider Details

I. General information

NPI: 1467988832
Provider Name (Legal Business Name): REVIVOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11464 S PARKWAY PLAZA DR SUITE 300
SOUTH JORDAN UT
84095-6052
US

IV. Provider business mailing address

11464 S PARKWAY PLAZA DR SUITE 300
SOUTH JORDAN UT
84095-6052
US

V. Phone/Fax

Practice location:
  • Phone: 801-987-8653
  • Fax: 801-727-8177
Mailing address:
  • Phone: 801-987-8653
  • Fax: 801-727-8177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number9258138-1205
License Number StateUT

VIII. Authorized Official

Name: DR. CHRISTOPHER PATRICK KELLY
Title or Position: MEDICAL DIRECTOR/OWNER
Credential: M.D.
Phone: 801-987-8653