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General NPI Number Information
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NPI Number | 1528791514
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Entity Type | Organization
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Legal Business Name | REVITALIZE THERAPY, LLC
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Dates
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Enumeration Date | 07/06/2022
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Last Update Date | 07/06/2022
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Provider Practice Location Address
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Address Line | 523 N WASHINGTON AVE
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City | DURANT
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State | OK
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Zip | 74701-3403
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Country | US
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Telephone | 580-634-2423
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Fax |
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Provider Business Mailing Address
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Address Line | 1802 JUANITAS LN
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City | KINGSTON
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State | OK
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Zip | 73439-5477
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Country | US
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Telephone | 580-579-8114
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. GINA HATFIELD
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Credential | MOT, OTR/L
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Telephone | 580-579-8114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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