Organization
REVIVAL IV AND WELLNESS CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KEISHA ASANTE (FNP)
(475) 314-3011
Entity
Organization
Contact information
Practice address
12 PROGRESS DR STE 1D, SHELTON, CT 06484-6290
(475) 314-3011
(475) 314-3011
Mailing address
120 LONGVIEW DR, STRATFORD, CT 06614-1398
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Enumeration date
02/20/2024
Last updated
02/20/2024
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