=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548082274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE WOUND CARE GA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2024
-----------------------------------------------------
Last Update Date | 10/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 980 ROWLAND ST STE 5140 #1111
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-760-6216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 980 ROWLAND ST STE 5140 #1111
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-760-6216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | PAUL DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-760-6216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------