Provider Demographics
NPI:1912448754
Name:REVIVE HORMONE CLINIC PLLC
Entity Type:Organization
Organization Name:REVIVE HORMONE CLINIC PLLC
Other - Org Name:REVIVE THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:405-703-8882
Mailing Address - Street 1:13316 S WESTERN AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-7302
Mailing Address - Country:US
Mailing Address - Phone:405-703-8882
Mailing Address - Fax:405-237-3799
Practice Address - Street 1:13316 S WESTERN AVE
Practice Address - Street 2:SUITE F
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-7302
Practice Address - Country:US
Practice Address - Phone:405-703-8882
Practice Address - Fax:405-237-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service