Healthcare Provider Details

I. General information

NPI: 1912448754
Provider Name (Legal Business Name): REVIVE HORMONE CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13316 S WESTERN AVE SUITE F
OKLAHOMA CITY OK
73170-7302
US

IV. Provider business mailing address

13316 S WESTERN AVE SUITE F
OKLAHOMA CITY OK
73170-7302
US

V. Phone/Fax

Practice location:
  • Phone: 405-703-8882
  • Fax: 405-237-3799
Mailing address:
  • Phone: 405-703-8882
  • Fax: 405-237-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ERNEST BYRON FOSTER II
Title or Position: MANAGER
Credential: MD
Phone: 405-703-8882