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General NPI Number Information
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NPI Number | 1902577554
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Entity Type | Organization
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Legal Business Name | REVIVE FAMILY MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 09/23/2021
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Last Update Date | 11/18/2021
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Provider Practice Location Address
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Address Line | 3549 BLUECUTT RD
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City | COLUMBUS
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State | MS
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Zip | 39705-1324
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Country | US
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Telephone | 662-386-1541
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Fax |
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Provider Business Mailing Address
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Address Line | 3549 BLUECUTT RD
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City | COLUMBUS
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State | MS
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Zip | 39705-1324
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Country | US
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Telephone | 662-570-4174
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Fax | 662-570-4108
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MR. MICAH ALEXANDER GRANT
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Credential | FNP
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Telephone | 662-570-4174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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