Healthcare Provider Details

I. General information

NPI: 1558275008
Provider Name (Legal Business Name): REVIVE WELLNESS CLINIC OF STARKVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RUSSELL ST STE 19
STARKVILLE MS
39759-3398
US

IV. Provider business mailing address

100 RUSSELL ST STE 19
STARKVILLE MS
39759-3398
US

V. Phone/Fax

Practice location:
  • Phone: 662-801-5795
  • Fax:
Mailing address:
  • Phone: 662-801-5795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: SARAH CLARK
Title or Position: MANAGER
Credential:
Phone: 662-801-5795