Provider Demographics
NPI:1467988832
Name:REVIVOLOGY
Entity Type:Organization
Organization Name:REVIVOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-987-8653
Mailing Address - Street 1:11464 S PARKWAY PLAZA DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-6052
Mailing Address - Country:US
Mailing Address - Phone:801-987-8653
Mailing Address - Fax:801-727-8177
Practice Address - Street 1:11464 S PARKWAY PLAZA DR
Practice Address - Street 2:SUITE 300
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-6052
Practice Address - Country:US
Practice Address - Phone:801-987-8653
Practice Address - Fax:801-727-8177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9258138-1205261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center