MEDICARE: REVIVE THERAPY PLUS WELLNESS

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
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1982289260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE THERAPY PLUS WELLNESS

Provider Business Mailing Address
First Line	:	629 SW 89TH ST.
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-9337
Country	:	US
Telephone Number	:	405-493-9955
Fax Number	:	405-682-2488

Provider Business Practice Location Address
First Line	:	629 SW 89TH ST.
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-9337
Country	:	US
Telephone Number	:	405-493-9955
Fax Number	:	405-682-2488

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST
Name	:	SARAH HENDRIX
Credential	:
Telephone Number	:	405-493-9955

Provider Enumeration Date	:	03/17/2021
Last Update Date	:	11/02/2021

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Directions to “REVIVE THERAPY PLUS WELLNESS ” Practice Location

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