Healthcare Provider Details

I. General information

NPI: 1346157658
Provider Name (Legal Business Name): REVIVE HYDRATION AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 CANAL STREET UNIT 1
LAKE CHARLES LA
70605
US

IV. Provider business mailing address

4100 CANAL STREET UNIT 1
LAKE CHARLES LA
70605
US

V. Phone/Fax

Practice location:
  • Phone: 337-485-2200
  • Fax:
Mailing address:
  • Phone: 337-485-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BLAIR ALIZABETH SNIDER
Title or Position: OWNER/MANAGING MEMBER
Credential: APRN, FNP-BC
Phone: 337-794-0455