MEDICARE: REVITALIZE ALABAMA L.L.C

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	:	1942975180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVITALIZE ALABAMA L.L.C

Provider Business Mailing Address
First Line	:	PO BOX 2738
Second Line	:
City	:	OPELIKA
State	:	AL
Zip	:	36803-2738
Country	:	US
Telephone Number	:	334-734-7973
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 1ST STREET
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36830-0000
Country	:	US
Telephone Number	:	334-734-7973
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TRAVIS WOODLEY
Credential	:	CRNP
Telephone Number	:	334-734-7973

Provider Enumeration Date	:	08/10/2021
Last Update Date	:	10/06/2021

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