MEDICARE: REVIVAL WOUND SPECIALISTS 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	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1689531709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVAL WOUND SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	302 BERMUDA RDG
Second Line	:
City	:	PERRY
State	:	GA
Zip	:	31069-8756
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 BERMUDA RDG
Second Line	:
City	:	PERRY
State	:	GA
Zip	:	31069-8756
Country	:	US
Telephone Number	:	470-979-7018
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAT LE
Credential	:	NP
Telephone Number	:	470-979-7018

Provider Enumeration Date	:	01/09/2026
Last Update Date	:	01/09/2026

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