Provider Demographics
NPI:1992588750
Name:REVIVED VITALITY
Entity type:Organization
Organization Name:REVIVED VITALITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNINGS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:843-855-2299
Mailing Address - Street 1:606 BALD EAGLE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MARCO ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:34145-2731
Mailing Address - Country:US
Mailing Address - Phone:843-855-2299
Mailing Address - Fax:843-353-2564
Practice Address - Street 1:1301 48TH AVE N # A-2
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5427
Practice Address - Country:US
Practice Address - Phone:843-580-3694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center