MEDICARE: REVIVED VITALITY

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1992588750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVED VITALITY

Provider Business Mailing Address
First Line	:	606 BALD EAGLE DR STE 201
Second Line	:
City	:	MARCO ISLAND
State	:	FL
Zip	:	34145-2731
Country	:	US
Telephone Number	:	843-855-2299
Fax Number	:	843-353-2564

Provider Business Practice Location Address
First Line	:	1301 48TH AVE N # A-2
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5427
Country	:	US
Telephone Number	:	843-580-3694
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	DR. JENNINGS MICHAEL PERRY
Credential	:	DNP
Telephone Number	:	843-855-2299

Provider Enumeration Date	:	08/16/2023
Last Update Date	:	08/16/2023

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1851684674 — JENNINGS MICHAEL PERRY DNP
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Practice Fax:

Directions to “REVIVED VITALITY ” Practice Location

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