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General NPI Number Information
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NPI Number | 1457225161
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Entity Type | Organization
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Legal Business Name | REVIVE THERAPEUTIC CENTER
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Dates
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Enumeration Date | 10/04/2025
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Last Update Date | 10/04/2025
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Provider Practice Location Address
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Address Line | 18216 PRESTON RD STE B-3
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City | DALLAS
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State | TX
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Zip | 75252-5412
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Country | US
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Telephone | 813-856-6029
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Fax |
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Provider Business Mailing Address
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Address Line | 6901 HANSELL RD APT 6313
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City | PLANO
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State | TX
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Zip | 75024-4217
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Country | US
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Telephone | 813-856-6029
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Fax |
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Authorized Official
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Title or Position | LICENSED MASSAGE THERAPIST
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Name | KYRA AZELIA MCMILLAN
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Credential |
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Telephone | 813-885-6029
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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