Healthcare Provider Details

I. General information

NPI: 1013755412
Provider Name (Legal Business Name): REVIVE-
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9450 PINECROFT DR
THE WOODLANDS TX
77380-3220
US

IV. Provider business mailing address

4029 N 72ND ST
MILWAUKEE WI
53216-1033
US

V. Phone/Fax

Practice location:
  • Phone: 262-510-3784
  • Fax:
Mailing address:
  • Phone: 262-510-3784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MS. LAFREDDRIA A HANNIBLE
Title or Position: DIRECTOR
Credential:
Phone: 262-510-3784