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General NPI Number Information
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NPI Number | 1932732187
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Entity Type | Organization
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Legal Business Name | REVIVE WELLNESS, PC
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Dates
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Enumeration Date | 02/17/2020
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Last Update Date | 02/17/2020
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Provider Practice Location Address
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Address Line | 850 W MAIN ST
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City | ROGERSVILLE
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State | TN
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Zip | 37857-3663
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Country | US
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Telephone | 423-500-0266
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Fax |
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Provider Business Mailing Address
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Address Line | 850 W MAIN ST
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City | ROGERSVILLE
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State | TN
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Zip | 37857-3663
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Country | US
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Telephone | 423-500-0266
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | CRYSTAL DYER
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Credential | MD
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Telephone | 423-552-1531
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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