Provider Demographics
NPI:1104538768
Name:REIVITALIZE THERAPY INFUSIONS & HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:REIVITALIZE THERAPY INFUSIONS & HEALTH SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:662-351-2035
Mailing Address - Street 1:PO BOX 1744
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-8544
Mailing Address - Country:US
Mailing Address - Phone:662-351-2035
Mailing Address - Fax:662-351-2045
Practice Address - Street 1:220 SUNFLOWER AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-4221
Practice Address - Country:US
Practice Address - Phone:662-351-2035
Practice Address - Fax:662-351-2045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No251F00000XAgenciesHome Infusion
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center