Healthcare Provider Details

I. General information

NPI: 1902724776
Provider Name (Legal Business Name): REVIVEWAVE THERAPEUTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6399 GOODMAN RD STE 105
OLIVE BRANCH MS
38654-7063
US

IV. Provider business mailing address

6399 GOODMAN RD STE 105
OLIVE BRANCH MS
38654-7063
US

V. Phone/Fax

Practice location:
  • Phone: 662-300-6822
  • Fax:
Mailing address:
  • Phone: 662-300-6822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JACK CHANDLER PAPA
Title or Position: OWNER / FOUNDER
Credential: MSN, APRN, FNP-C
Phone: 662-300-6822