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General NPI Number Information
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NPI Number | 1659994911
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Entity Type | Organization
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Legal Business Name | REVISION HEALTH SERVICES, PLLC
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Dates
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Enumeration Date | 05/21/2020
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Last Update Date | 05/29/2020
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Provider Practice Location Address
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Address Line | 131 VALLEY GROVE DR
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City | PONTE VEDRA
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State | FL
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Zip | 32081-6165
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Country | US
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Telephone | 309-267-9873
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Fax |
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Provider Business Mailing Address
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Address Line | 908 W 1ST ST
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City | SPRING VALLEY
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State | IL
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Zip | 61362-1135
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Country | US
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Telephone | 309-267-9873
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MICHAEL DERRY
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Credential | PT
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Telephone | 309-267-9873
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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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 | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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