Provider Demographics
NPI:1871311076
Name:REVIVAL MED CENTERS, LLC
Entity type:Organization
Organization Name:REVIVAL MED CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:ALBA
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-886-8459
Mailing Address - Street 1:8353 SW 124TH ST STE 207A
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5847
Mailing Address - Country:US
Mailing Address - Phone:786-443-5833
Mailing Address - Fax:
Practice Address - Street 1:8353 SW 124TH ST STE 207A
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-5847
Practice Address - Country:US
Practice Address - Phone:786-443-5833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty