Healthcare Provider Details

I. General information

NPI: 1306758586
Provider Name (Legal Business Name): REVIVE INK STUDIO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12205 COUNTY LINE RD STE F
MADISON AL
35758-7720
US

IV. Provider business mailing address

209 WILSON HALL DR
MADISON AL
35757-8701
US

V. Phone/Fax

Practice location:
  • Phone: 256-400-0771
  • Fax:
Mailing address:
  • Phone: 256-400-0771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MS. ERIKA LYNN JOHN
Title or Position: OWNER
Credential:
Phone: 904-907-0143