1558128314 NPI number — REVIVE HYDRATION AND FUNCTIONAL HEALTH LLC

Table of content: (NPI 1497202600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558128314 NPI number — REVIVE HYDRATION AND FUNCTIONAL HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVE HYDRATION AND FUNCTIONAL HEALTH LLC
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:
1558128314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1150 WARD STREET EXT W STE B1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31533-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-720-5450
Provider Business Mailing Address Fax Number:
866-611-2696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 WARD STREET EXT W STE B1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLAS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31533-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-720-5450
Provider Business Practice Location Address Fax Number:
866-611-2696
Provider Enumeration Date:
02/28/2024

Additional Information

Authorized Official

Authorized Official Last Name:
GUESS
Authorized Official First Name:
BOBBY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
912-720-5450

Provider Taxonomy Codes

  • Taxonomy code: 261QI0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com