Healthcare Provider Details

I. General information

NPI: 1750801205
Provider Name (Legal Business Name): REVIVE MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 OLD NORCROSS RD STE A
LAWRENCEVILLE GA
30046-4312
US

IV. Provider business mailing address

753 OLD NORCROSS RD STE A
LAWRENCEVILLE GA
30046-4312
US

V. Phone/Fax

Practice location:
  • Phone: 770-545-8888
  • Fax: 770-545-8889
Mailing address:
  • Phone: 770-545-8888
  • Fax: 770-545-8889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: MICHAEL D SCHULMAN
Title or Position: OWNER
Credential:
Phone: 770-545-8888