Provider Demographics
NPI:1508749664
Name:REVIVE5 PAIN MANAGEMENT LLC
Entity type:Organization
Organization Name:REVIVE5 PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:OSAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUDAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-476-6272
Mailing Address - Street 1:801 N ORANGE AVE STE 710
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-5202
Mailing Address - Country:US
Mailing Address - Phone:407-333-0496
Mailing Address - Fax:
Practice Address - Street 1:801 N ORANGE AVE STE 710
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-5202
Practice Address - Country:US
Practice Address - Phone:407-333-0496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology