Provider Demographics
NPI:1477134203
Name:REVISION INK LLC
Entity Type:Organization
Organization Name:REVISION INK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMAINTE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GODEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-945-0631
Mailing Address - Street 1:615 EASY ROCK LANDING DR
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-7775
Mailing Address - Country:US
Mailing Address - Phone:337-945-0631
Mailing Address - Fax:
Practice Address - Street 1:1007 BERTRAND PKWY
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-8025
Practice Address - Country:US
Practice Address - Phone:337-945-0631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, MedicalGroup - Single Specialty