Healthcare Provider Details

I. General information

NPI: 1124764030
Provider Name (Legal Business Name): PD REVIVAL MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 SADDLE DR SUITE 6B
HELENA MT
59601-8644
US

IV. Provider business mailing address

3130 SADDLE DR STUITE 6
HELENA MT
59601-8644
US

V. Phone/Fax

Practice location:
  • Phone: 307-272-0843
  • Fax:
Mailing address:
  • Phone: 307-272-0843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: HANNA POWERS
Title or Position: PMHNP
Credential:
Phone: 307-272-0843