1871369272 NPI number — REVITALIZE IV HYDRATION AND WELLNESS CLINC LLC

Table of content: (NPI 1871369272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871369272 NPI number — REVITALIZE IV HYDRATION AND WELLNESS CLINC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVITALIZE IV HYDRATION AND WELLNESS CLINC LLC
Provider Last Name:
Provider First Name:
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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:
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NPI Number Information

NPI Number:
1871369272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2704 PHILLIPS DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72401-7399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-955-5701
Provider Business Mailing Address Fax Number:
302-209-5619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2704 PHILLIPS DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JONESBORO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72401-7399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-955-5701
Provider Business Practice Location Address Fax Number:
302-209-5619
Provider Enumeration Date:
11/28/2023

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
FELICA
Authorized Official Middle Name:
Authorized Official Title or Position:
FNP
Authorized Official Telephone Number:
870-273-4164

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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