Provider Demographics
NPI:1710290622
Name:REVIVE RESPIRATORY AND DME LLC
Entity Type:Organization
Organization Name:REVIVE RESPIRATORY AND DME LLC
Other - Org Name:REVIVE RESPIRATORY AND DME LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERA
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:318-687-8813
Mailing Address - Street 1:9591 WALLACE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7535
Mailing Address - Country:US
Mailing Address - Phone:318-687-8813
Mailing Address - Fax:318-687-8813
Practice Address - Street 1:9591 WALLACE LAKE RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7535
Practice Address - Country:US
Practice Address - Phone:318-687-8813
Practice Address - Fax:318-687-8813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALT3525332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies