=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174349104
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE HEALTHCARE CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2024
-----------------------------------------------------
Last Update Date | 03/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1221 WEST AIRPORT FWY STE# 209 UNIT B
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-777-2703
-----------------------------------------------------
Fax | 817-865-1530
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1221 WEST AIRPORT FWY STE# 209 UNIT B
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-777-2703
-----------------------------------------------------
Fax | 817-865-1530
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHEKWUBE MARTHA OKOLI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-567-9974
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------