Healthcare Provider Details

I. General information

NPI: 1740996636
Provider Name (Legal Business Name): REVIVE MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 11TH AVE
HALEYVILLE AL
35565-1506
US

IV. Provider business mailing address

PO BOX 1016
HALEYVILLE AL
35565-1016
US

V. Phone/Fax

Practice location:
  • Phone: 205-485-7822
  • Fax: 260-399-4004
Mailing address:
  • Phone: 205-485-7822
  • Fax: 260-399-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LARRY JAKE PICKENS
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 205-485-7822