Provider Demographics
NPI:1093345969
Name:REVIVE NUTRITION LLC
Entity Type:Organization
Organization Name:REVIVE NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SABADA
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:314-369-3159
Mailing Address - Street 1:1217 BEACON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5398
Mailing Address - Country:US
Mailing Address - Phone:314-369-3159
Mailing Address - Fax:
Practice Address - Street 1:1330 BEACON ST STE 342
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3203
Practice Address - Country:US
Practice Address - Phone:314-369-3159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-20
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty