Organization
REVIVAL VENTURES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DANIEL WOMAC MD (SOLE OWNDER)
(504) 800-8058
Entity
Organization
Contact information
Practice address
3572 PRESERVE DR, MIRAMAR BEACH, FL 32550-1802
(504) 233-9818
(504) 949-0599
Mailing address
425 UPSTREAM ST, RIVER RIDGE, LA 70123-2835
(504) 812-3090
(504) 387-6538
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
ME153935
FLORIDA STATE LICENSE
FL
Enumeration date
08/10/2022
Last updated
04/04/2023
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