=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669087045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2020
-----------------------------------------------------
Last Update Date | 09/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 S SCENIC
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-777-0797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 S SCENIC
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-777-0797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. TROY MORRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-777-0797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BP3500X
-----------------------------------------------------
Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335G00000X
-----------------------------------------------------
Taxonomy Name | Medical Foods Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------