Healthcare Provider Details

I. General information

NPI: 1548082274
Provider Name (Legal Business Name): REVIVE WOUND CARE GA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 10/24/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 ROWLAND ST STE 5140 #1111
CLARKSTON GA
30021
US

IV. Provider business mailing address

980 ROWLAND ST STE 5140 #1111
CLARKSTON GA
30021
US

V. Phone/Fax

Practice location:
  • Phone: 951-760-6216
  • Fax:
Mailing address:
  • Phone: 951-760-6216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: PAUL DAVIS
Title or Position: MANAGER
Credential:
Phone: 951-760-6216