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General NPI Number Information
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NPI Number | 1699416818
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Entity Type | Organization
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Legal Business Name | REVOLUTION PERFORMANCE, LLC
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Dates
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Enumeration Date | 04/03/2022
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Last Update Date | 04/03/2022
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Provider Practice Location Address
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Address Line | 4516 KENNY RD STE B
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City | COLUMBUS
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State | OH
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Zip | 43220-3786
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Country | US
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Telephone | 614-859-2785
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Fax |
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Provider Business Mailing Address
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Address Line | 2759 BERLIN STATION RD
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City | DELAWARE
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State | OH
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Zip | 43015-9406
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Country | US
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Telephone | 618-670-3788
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | DR. RYAN A QUEEN
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Credential | PT, DPT, CSCS, PN1
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Telephone | 618-670-3788
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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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