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General NPI Number Information
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NPI Number | 1255125019
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Entity Type | Organization
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Legal Business Name | REVITALIZE HEALTH AND WELLNESS LLC
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Dates
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Enumeration Date | 04/07/2025
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Last Update Date | 09/05/2025
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Provider Practice Location Address
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Address Line | 16339 SILVER SPRING DR
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City | CHOCTAW
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State | OK
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Zip | 73020-5807
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Country | US
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Telephone | 918-633-0622
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Fax |
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Provider Business Mailing Address
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Address Line | 16339 SILVER SPRING DR
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City | CHOCTAW
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State | OK
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Zip | 73020-5807
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PART OWNER
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Name | BETHANY BIA
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Credential |
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Telephone | 918-633-0622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207QS1201X
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Taxonomy Name | Sleep Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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