MEDICARE: REVIVE RESPIRATORY AND DME LLC

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	332BX2000X	Oxygen Equipment & Supplies (DME)	LT3525	LA

General Provider Information

NPI Number	:	1710290622
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE RESPIRATORY AND DME LLC

Provider Business Mailing Address
First Line	:	9591 WALLACE LAKE RD
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-7535
Country	:	US
Telephone Number	:	318-687-8813
Fax Number	:	318-687-8813

Provider Business Practice Location Address
First Line	:	9591 WALLACE LAKE RD
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-7535
Country	:	US
Telephone Number	:	318-687-8813
Fax Number	:	318-687-8813

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	MRS. VERA MITCHELL WARE
Credential	:	RRT
Telephone Number	:	318-687-8813

Provider Enumeration Date	:	07/20/2010
Last Update Date	:	07/22/2010

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