# REVIVE FAMILY MEDICAL CLINIC, LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1902577554
- **Authorized official:** MR. MICAH ALEXANDER GRANT FNP (NURSE PRACTITIONER)
- **Authorized official phone:** (662) 570-4174

## Contact information

- **Practice address:** 3549 BLUECUTT RD, COLUMBUS, MS 39705-1324
- **Practice address phone:** (662) 386-1541
- **Mailing address:** 3549 BLUECUTT RD, COLUMBUS, MS 39705-1324
- **Mailing address phone:** (662) 570-4174
- **Mailing address fax:** (662) 570-4108

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 09/23/2021
- **Last updated:** 11/18/2021

## 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 |