Provider Demographics
NPI:1942975180
Name:REVITALIZE ALABAMA L.L.C
Entity Type:Organization
Organization Name:REVITALIZE ALABAMA L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:334-734-7973
Mailing Address - Street 1:PO BOX 2738
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36803-2738
Mailing Address - Country:US
Mailing Address - Phone:334-734-7973
Mailing Address - Fax:
Practice Address - Street 1:105 1ST STREET
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-0000
Practice Address - Country:US
Practice Address - Phone:334-734-7973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty