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General NPI Number Information
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NPI Number | 1952815466
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Entity Type | Organization
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Legal Business Name | REVIVIFY BIOLOGICS
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Dates
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Enumeration Date | 11/20/2017
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Last Update Date | 11/20/2017
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Provider Practice Location Address
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Address Line | 4100 HERITAGE AVE
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City | GRAPEVINE
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State | TX
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Zip | 76051-5714
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Country | US
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Telephone | 817-886-4319
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Fax |
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Provider Business Mailing Address
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Address Line | 62 MAIN ST STE 110
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City | COLLEYVILLE
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State | TX
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Zip | 76034-2931
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Country | US
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Telephone | 817-886-4319
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTIONER
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Name | ELLEN ROSE BECKER
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Credential | AGNP
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Telephone | 817-886-4319
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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