Provider Demographics
NPI:1871369272
Name:REVITALIZE IV HYDRATION AND WELLNESS CLINC LLC
Entity type:Organization
Organization Name:REVITALIZE IV HYDRATION AND WELLNESS CLINC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:FELICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:870-273-4164
Mailing Address - Street 1:2704 PHILLIPS DR STE A
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7399
Mailing Address - Country:US
Mailing Address - Phone:870-955-5701
Mailing Address - Fax:302-209-5619
Practice Address - Street 1:2704 PHILLIPS DR STE A
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7399
Practice Address - Country:US
Practice Address - Phone:870-955-5701
Practice Address - Fax:302-209-5619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-28
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty