MEDICARE: REVIVEEASE CARE, 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	2083P0901X	Public Health & General Preventive Medicine Physician

General Provider Information

NPI Number	:	1720815111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVEEASE CARE, LLC

Provider Business Mailing Address
First Line	:	5626 POST OAK TRL
Second Line	:
City	:	BESSEMER
State	:	AL
Zip	:	35022-4714
Country	:	US
Telephone Number	:	256-318-7811
Fax Number	:

Provider Business Practice Location Address
First Line	:	5626 POST OAK TRL
Second Line	:
City	:	BESSEMER
State	:	AL
Zip	:	35022-4714
Country	:	US
Telephone Number	:	256-318-7811
Fax Number	:

Authorized Official
Title or Position	:	OWNER/EXERCISE PHYSIOLOGIST
Name	:	THOMAS GAMBLE DAVIS
Credential	:
Telephone Number	:	256-318-7811

Provider Enumeration Date	:	09/18/2024
Last Update Date	:	09/20/2024

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