Provider Demographics
NPI:1114794385
Name:REVIVE HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:REVIVE HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF ENTUITY
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:501-337-6246
Mailing Address - Street 1:121 DAISY LN
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-5988
Mailing Address - Country:US
Mailing Address - Phone:501-337-6246
Mailing Address - Fax:
Practice Address - Street 1:1636 HIGDON FERRY RD
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6912
Practice Address - Country:US
Practice Address - Phone:501-337-6246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty