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
—
—
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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