Revive Family Medical Clinic, LLC
Clinic/Center in Columbus, MS. Organization (NPI-2).
NPI number1902577554
StatusActive
Last updated in NPPESNov 18, 2021
Details
- NPI
- 1902577554
- Entity type
- Organization (NPI-2)
- Legal business name
- Revive Family Medical Clinic, LLC
- Organization subpart
- No
- Enumeration date
- Sep 23, 2021
- Certification date
- Nov 18, 2021
- Last updated
- Nov 18, 2021
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 261Q00000X | Clinic/Center | – | – | Yes |
Practice location
3549 Bluecutt RdColumbus, MS 39705-1324
Phone 662-386-1541
Mailing address
3549 Bluecutt RdColumbus, MS 39705-1324
Phone 662-570-4174 · Fax 662-570-4108
Authorized official
Micah Alexander Grant
Nurse Practitioner
6625704174
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