=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710290622
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE RESPIRATORY AND DME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2010
-----------------------------------------------------
Last Update Date | 07/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9591 WALLACE LAKE RD
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71106-7535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-687-8813
-----------------------------------------------------
Fax | 318-687-8813
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9591 WALLACE LAKE RD
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71106-7535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-687-8813
-----------------------------------------------------
Fax | 318-687-8813
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MRS. VERA MITCHELL WARE
-----------------------------------------------------
Credential | RRT
-----------------------------------------------------
Telephone | 318-687-8813
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number | LT3525
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------