MEDICARE: REVISION INK LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZA2600X	Medical Art Specialist/Technologist

General Provider Information

NPI Number	:	1477134203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVISION INK LLC

Provider Business Mailing Address
First Line	:	615 EASY ROCK LANDING DR
Second Line	:
City	:	BROUSSARD
State	:	LA
Zip	:	70518-7775
Country	:	US
Telephone Number	:	337-945-0631
Fax Number	:

Provider Business Practice Location Address
First Line	:	1007 BERTRAND PKWY
Second Line	:
City	:	BROUSSARD
State	:	LA
Zip	:	70518-8025
Country	:	US
Telephone Number	:	337-945-0631
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	AMAINTE B GODEAUX
Credential	:
Telephone Number	:	337-945-0631

Provider Enumeration Date	:	04/14/2021
Last Update Date	:	04/14/2021

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Directions to “REVISION INK LLC ” Practice Location

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