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General NPI Number Information
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NPI Number | 1740996636
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Entity Type | Organization
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Legal Business Name | REVIVE MEDICAL CENTER LLC
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Dates
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Enumeration Date | 01/25/2023
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Last Update Date | 02/22/2023
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Provider Practice Location Address
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Address Line | 1728 11TH AVE
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City | HALEYVILLE
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State | AL
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Zip | 35565-1506
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Country | US
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Telephone | 205-485-7822
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Fax | 260-399-4004
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Provider Business Mailing Address
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Address Line | PO BOX 1016
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City | HALEYVILLE
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State | AL
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Zip | 35565-1016
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Country | US
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Telephone | 205-485-7822
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Fax | 260-399-4004
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | LARRY JAKE PICKENS
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Credential |
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Telephone | 205-485-7822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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