1992556369 NPI number — REVIVE HYDRATION & WELLNESS LLC

Table of content: (NPI 1992556369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992556369 NPI number — REVIVE HYDRATION & WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVE HYDRATION & WELLNESS 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:
NANUK HEALTH
Provider Other Organization Name Type Code:
5
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:
1992556369
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1309 COFFEEN AVE STE 1417
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERIDAN
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82801-5777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-282-9022
Provider Business Mailing Address Fax Number:
844-332-3887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 SHEFFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49017-8210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
692-282-9022
Provider Business Practice Location Address Fax Number:
844-332-3887
Provider Enumeration Date:
04/01/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ABRAHAM
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
JOHAN
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
269-282-6005

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QI0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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