Provider Demographics
NPI:1952815466
Name:REVIVIFY BIOLOGICS
Entity Type:Organization
Organization Name:REVIVIFY BIOLOGICS
Other - Org Name:REVIVIFY BIOLOGICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:AGNP
Authorized Official - Phone:817-886-4319
Mailing Address - Street 1:62 MAIN ST STE 110
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-2931
Mailing Address - Country:US
Mailing Address - Phone:817-886-4319
Mailing Address - Fax:
Practice Address - Street 1:4100 HERITAGE AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5714
Practice Address - Country:US
Practice Address - Phone:817-886-4319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty