Provider Demographics
NPI:1093742900
Name:HEALTH REVIVAL MEDICAL PC
Entity Type:Organization
Organization Name:HEALTH REVIVAL MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEKSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-891-8822
Mailing Address - Street 1:21 GOODAL STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3325
Mailing Address - Country:US
Mailing Address - Phone:718-891-8822
Mailing Address - Fax:718-891-8823
Practice Address - Street 1:HEALTH REVIVAL MEDICAL PC
Practice Address - Street 2:162 BRIGHTON STREET
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5237
Practice Address - Country:US
Practice Address - Phone:718-891-8822
Practice Address - Fax:718-891-8823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223381207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty