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Organization
REVIVE FAMILY MEDICAL CLINIC, LLC
Active
Organization
REVIVE FAMILY MEDICAL CLINIC, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICAH ALEXANDER GRANT FNP (NURSE PRACTITIONER)
(662) 570-4174
Entity
Organization
Contact information
Practice address
3549 BLUECUTT RD, COLUMBUS, MS 39705-1324
(662) 386-1541
Mailing address
3549 BLUECUTT RD, COLUMBUS, MS 39705-1324
(662) 570-4174
(662) 570-4108
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
06975501
—
MS
01
—
1437558061
NPI-1
—
01
—
F0115273
AANP
—
01
—
R874310
MISSISSIPPI BOARD OF NURSING- RN
MS
Enumeration date
09/23/2021
Last updated
11/18/2021
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