Provider Demographics
NPI:1235939612
Name:REVIVE WELLNESS CENTER INC
Entity type:Organization
Organization Name:REVIVE WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANWAR
Authorized Official - Middle Name:MUSTAFA
Authorized Official - Last Name:ABUKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-707-6834
Mailing Address - Street 1:2704 14TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1127
Mailing Address - Country:US
Mailing Address - Phone:612-987-2990
Mailing Address - Fax:612-987-2990
Practice Address - Street 1:2704 14TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1127
Practice Address - Country:US
Practice Address - Phone:612-987-2990
Practice Address - Fax:612-987-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-15
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care