Provider Demographics
NPI:1427404730
Name:REVOLUTION THERAPY & FITNESS LLC
Entity Type:Organization
Organization Name:REVOLUTION THERAPY & FITNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPY ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:LLEWELLYN
Authorized Official - Middle Name:SEAN
Authorized Official - Last Name:WORSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-323-0174
Mailing Address - Street 1:215 BLOSSOM ST
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-3516
Mailing Address - Country:US
Mailing Address - Phone:843-323-0174
Mailing Address - Fax:888-856-3189
Practice Address - Street 1:8626 DORCHESTER RD STE 103
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7328
Practice Address - Country:US
Practice Address - Phone:843-964-4996
Practice Address - Fax:888-856-3189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-05
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7597Medicaid