Provider Demographics
NPI:1992002695
Name:REVIVE HEALTH MEDICAL SUPPLIES
Entity type:Organization
Organization Name:REVIVE HEALTH MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:972-263-7042
Mailing Address - Street 1:PO BOX 92282
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0103
Mailing Address - Country:US
Mailing Address - Phone:972-263-7042
Mailing Address - Fax:972-263-7046
Practice Address - Street 1:504 N CARRIER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-5428
Practice Address - Country:US
Practice Address - Phone:972-263-7042
Practice Address - Fax:972-263-7046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies