MEDICARE: REVIVE MED PARTNERS I 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1881400323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE MED PARTNERS I LLC

Provider Business Mailing Address
First Line	:	2570 JUSTIN RD STE 160
Second Line	:
City	:	HIGHLAND VILLAGE
State	:	TX
Zip	:	75077-3055
Country	:	US
Telephone Number	:	972-236-7060
Fax Number	:

Provider Business Practice Location Address
First Line	:	2570 JUSTIN RD STE 160
Second Line	:
City	:	HIGHLAND VILLAGE
State	:	TX
Zip	:	75077-3055
Country	:	US
Telephone Number	:	972-236-7060
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KYLE KALRA
Credential	:
Telephone Number	:	972-236-7060

Provider Enumeration Date	:	12/09/2024
Last Update Date	:	12/09/2024

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