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General NPI Number Information
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NPI Number | 1689531709
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Entity Type | Organization
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Legal Business Name | REVIVAL WOUND SPECIALISTS LLC
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Dates
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Enumeration Date | 01/09/2026
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Last Update Date | 01/09/2026
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Provider Practice Location Address
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Address Line | 302 BERMUDA RDG
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City | PERRY
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State | GA
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Zip | 31069-8756
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Country | US
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Telephone | 470-979-7018
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Fax |
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Provider Business Mailing Address
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Address Line | 302 BERMUDA RDG
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City | PERRY
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State | GA
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Zip | 31069-8756
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DAT LE
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Credential | NP
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Telephone | 470-979-7018
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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