Healthcare Provider Details

I. General information

NPI: 1659199008
Provider Name (Legal Business Name): REVIVE WOUND CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28496 RANCH ROAD 12 STE 200 # 105
DRIPPING SPRINGS TX
78620
US

IV. Provider business mailing address

13423 BLANCO RD UNIT 3255
SAN ANTONIO TX
78216-2187
US

V. Phone/Fax

Practice location:
  • Phone: 951-760-6216
  • Fax:
Mailing address:
  • Phone: 951-760-6216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHANNES NEUENDORF
Title or Position: OWNER
Credential: DO
Phone: 760-809-8654