Provider Demographics
NPI:1154826980
Name:CORE REVIVE / SOUL REVIVE LLC
Entity Type:Organization
Organization Name:CORE REVIVE / SOUL REVIVE LLC
Other - Org Name:CORE REVIVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:415-250-7118
Mailing Address - Street 1:16 QUEENS LN
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-1047
Mailing Address - Country:US
Mailing Address - Phone:707-559-5347
Mailing Address - Fax:
Practice Address - Street 1:16 QUEENS LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-1047
Practice Address - Country:US
Practice Address - Phone:707-559-5347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA846331163WD0400X, 163WN1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WN1003XNursing Service ProvidersRegistered NurseNutrition SupportGroup - Single Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Single Specialty