1457203879 NPI number — REVIVE PRIMARY CARE AND MEDSPA PLLC

Table of content: (NPI 1457203879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457203879 NPI number — REVIVE PRIMARY CARE AND MEDSPA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVE PRIMARY CARE AND MEDSPA PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457203879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2221 JACKSBORO PIKE STE A18
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA FOLLETTE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37766-3035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-408-7606
Provider Business Mailing Address Fax Number:
865-332-1923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2221 JACKSBORO PIKE STE A18
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA FOLLETTE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37766-3035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-408-7606
Provider Business Practice Location Address Fax Number:
865-332-1923
Provider Enumeration Date:
02/10/2026

Additional Information

Authorized Official

Authorized Official Last Name:
MARLOW
Authorized Official First Name:
HEIDI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
AGNP-CB
Authorized Official Telephone Number:
937-408-7606

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2026 www.npivalidator.com