Provider Demographics
NPI:1902577554
Name:REVIVE FAMILY MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:REVIVE FAMILY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-570-4174
Mailing Address - Street 1:3549 BLUECUTT RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1324
Mailing Address - Country:US
Mailing Address - Phone:662-570-4174
Mailing Address - Fax:662-570-4108
Practice Address - Street 1:3549 BLUECUTT RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1324
Practice Address - Country:US
Practice Address - Phone:662-386-1541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-23
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06975501Medicaid
MSR874310OtherMISSISSIPPI BOARD OF NURSING- RN
F0115273OtherAANP
1437558061OtherNPI-1