Provider Demographics
NPI:1184230674
Name:REVIVAL HEALTH
Entity Type:Organization
Organization Name:REVIVAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:MICHAELA
Authorized Official - Last Name:GUTSCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:862-219-8573
Mailing Address - Street 1:1343 MAIN ST STE 404
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-5621
Mailing Address - Country:US
Mailing Address - Phone:862-219-8573
Mailing Address - Fax:941-740-5496
Practice Address - Street 1:1343 MAIN ST STE 404
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-5621
Practice Address - Country:US
Practice Address - Phone:862-219-8573
Practice Address - Fax:941-740-5496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-20
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center