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General NPI Number Information
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NPI Number | 1255068425
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Entity Type | Organization
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Legal Business Name | REVIVE HEALTH AND WELLNESS, LLC
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Dates
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Enumeration Date | 08/06/2022
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Last Update Date | 08/06/2022
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Provider Practice Location Address
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Address Line | 2112 BIENVILLE BLVD STE M1
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City | OCEAN SPRINGS
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State | MS
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Zip | 39564-3027
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Country | US
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Telephone | 228-324-5347
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Fax |
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Provider Business Mailing Address
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Address Line | 17804 RIVERWALK DRIVE
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City | VANCLEAVE
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State | MS
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Zip | 39565
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Country | US
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Telephone | 228-324-5347
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TRACI J WHITE
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Credential | NP
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Telephone | 228-324-5347
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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