Organization
I-REVIVE PLLC
Active
Organization
I-REVIVE PLLC
Active
Other names
my medical massage
Organization subpart
No
Provider details
NPI number
Authorized official
MS. AMANDA M CONVERSE I LMT, CIMT, CPMT (CEO/FOUNDER)
(616) 377-8893
Entity
Organization
Contact information
Practice address
525 ELLIOTT AVE, GRAND HAVEN, MI 49417-1038
(616) 566-1603
(616) 607-8588
Mailing address
525 ELLIOTT AVE, GRAND HAVEN, MI 49417-1038
(616) 377-8893
(616) 607-8588
Taxonomy
Speciality
Code
Description
License number
State
2083P0500X
Preventive Medicine/Occupational Environmental Medicine Physician
Primary
—
—
251E00000X
Home Health Agency
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14997664
CAQH
MI
Enumeration date
09/28/2020
Last updated
11/05/2020
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