Provider Demographics
NPI:1699416818
Name:REVOLUTION PERFORMANCE, LLC
Entity Type:Organization
Organization Name:REVOLUTION PERFORMANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:QUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CSCS, PN1
Authorized Official - Phone:618-670-3788
Mailing Address - Street 1:2759 BERLIN STATION RD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-9406
Mailing Address - Country:US
Mailing Address - Phone:618-670-3788
Mailing Address - Fax:
Practice Address - Street 1:4516 KENNY RD STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3786
Practice Address - Country:US
Practice Address - Phone:614-859-2785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-03
Last Update Date:2022-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty