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General NPI Number Information
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NPI Number | 1669291308
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Entity Type | Organization
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Legal Business Name | REVIVE WELLNESS AND AESTHETICS LLC
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Dates
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Enumeration Date | 10/09/2024
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Last Update Date | 10/09/2024
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Provider Practice Location Address
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Address Line | 110A S MLK JR DR
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City | INDIANOLA
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State | MS
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Zip | 38751-2622
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Country | US
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Telephone | 662-445-2213
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Fax | 662-445-2214
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Provider Business Mailing Address
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Address Line | 110A S MLK JR DR
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City | INDIANOLA
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State | MS
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Zip | 38751-2622
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Country | US
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Telephone | 662-445-2213
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Fax | 662-445-2214
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Authorized Official
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Title or Position | CFNP/OWNER
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Name | EMILY AUST
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Credential | APRN
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Telephone | 662-445-2213
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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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