MEDICARE: REVITALIZE THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1528791514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVITALIZE THERAPY, LLC

Provider Business Mailing Address
First Line	:	1802 JUANITAS LN
Second Line	:
City	:	KINGSTON
State	:	OK
Zip	:	73439-5477
Country	:	US
Telephone Number	:	580-579-8114
Fax Number	:

Provider Business Practice Location Address
First Line	:	523 N WASHINGTON AVE
Second Line	:
City	:	DURANT
State	:	OK
Zip	:	74701-3403
Country	:	US
Telephone Number	:	580-634-2423
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. GINA HATFIELD
Credential	:	MOT, OTR/L
Telephone Number	:	580-579-8114

Provider Enumeration Date	:	07/06/2022
Last Update Date	:	07/06/2022

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