MEDICARE: REVIVE WHOLE LIFE SOLUTIONS 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1891371027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE WHOLE LIFE SOLUTIONS LLC

Provider Business Mailing Address
First Line	:	2524 KIRKLEY ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-4829
Country	:	US
Telephone Number	:	214-600-6060
Fax Number	:

Provider Business Practice Location Address
First Line	:	2524 KIRKLEY ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-4829
Country	:	US
Telephone Number	:	214-600-6060
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CARRIE MONROE
Credential	:
Telephone Number	:	214-600-6060

Provider Enumeration Date	:	03/18/2021
Last Update Date	:	03/18/2021

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