MEDICARE: REV HEALTH AND WELLNESS PLLC

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1881261519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REV HEALTH AND WELLNESS PLLC

Provider Business Mailing Address
First Line	:	630 DAYBREAK DR
Second Line	:
City	:	WAUKEE
State	:	IA
Zip	:	50263-8162
Country	:	US
Telephone Number	:	563-543-1234
Fax Number	:

Provider Business Practice Location Address
First Line	:	10619 AURORA AVE
Second Line	:
City	:	URBANDALE
State	:	IA
Zip	:	50322-7927
Country	:	US
Telephone Number	:	515-207-5002
Fax Number	:

Authorized Official
Title or Position	:	OWNER, PHYSICAL THERAPIST
Name	:	RYAN J DOMEYER
Credential	:	PT, DPT, CMPT
Telephone Number	:	563-543-1234

Provider Enumeration Date	:	06/10/2021
Last Update Date	:	06/10/2021

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