# REVITALIZE HEALTH AND WELLNESS LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1255125019
- **Authorized official:** BETHANY BIA (PART OWNER)
- **Authorized official phone:** (918) 633-0622

## Contact information

- **Practice address:** 16339 SILVER SPRING DR, CHOCTAW, OK 73020-5807
- **Practice address phone:** (918) 633-0622
- **Mailing address:** 16339 SILVER SPRING DR, CHOCTAW, OK 73020-5807

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 207QS1201X | Sleep Medicine (Family Medicine) Physician | — | — | — |
| 363L00000X | Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 04/07/2025
- **Last updated:** 09/05/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1629739891 | — | OK |
| 05 | — | 17770075764 | — | OK |