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General NPI Number Information
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NPI Number | 1942975180
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Entity Type | Organization
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Legal Business Name | REVITALIZE ALABAMA L.L.C
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Dates
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Enumeration Date | 08/10/2021
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Last Update Date | 10/06/2021
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Provider Practice Location Address
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Address Line | 105 1ST STREET
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City | AUBURN
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State | AL
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Zip | 36830-0000
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Country | US
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Telephone | 334-734-7973
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2738
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City | OPELIKA
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State | AL
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Zip | 36803-2738
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Country | US
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Telephone | 334-734-7973
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. TRAVIS WOODLEY
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Credential | CRNP
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Telephone | 334-734-7973
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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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