MEDICARE: REVIVE HEALTH & WELLNESS, PLLC

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	111NN0400X	Neurology Chiropractor

General Provider Information

NPI Number	:	1740976067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE HEALTH & WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	336 N PEACHTREE AVE
Second Line	:
City	:	COOKEVILLE
State	:	TN
Zip	:	38501-2551
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	336 N PEACHTREE AVE
Second Line	:
City	:	COOKEVILLE
State	:	TN
Zip	:	38501-2551
Country	:	US
Telephone Number	:	269-317-7577
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TREVOR D EASON
Credential	:	DC
Telephone Number	:	269-317-7577

Provider Enumeration Date	:	04/11/2023
Last Update Date	:	04/11/2023

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