=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427404730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVOLUTION THERAPY & FITNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2016
-----------------------------------------------------
Last Update Date | 08/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8626 DORCHESTER RD STE 103
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29420-7328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-964-4996
-----------------------------------------------------
Fax | 888-856-3189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 BLOSSOM ST
-----------------------------------------------------
City | GOOSE CREEK
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29445-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-323-0174
-----------------------------------------------------
Fax | 888-856-3189
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPY ASSISTANT
-----------------------------------------------------
Name | LLEWELLYN SEAN WORSHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-323-0174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------