Provider Demographics
NPI:1225677222
Name:REVIVE & REJUVENATE LLC
Entity Type:Organization
Organization Name:REVIVE & REJUVENATE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:785-550-1239
Mailing Address - Street 1:4110 ALMEDA RD, PO BOX 8321
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-4869
Mailing Address - Country:US
Mailing Address - Phone:785-550-1239
Mailing Address - Fax:
Practice Address - Street 1:3129 KINGSLEY DR STE 640
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8508
Practice Address - Country:US
Practice Address - Phone:281-901-1133
Practice Address - Fax:281-901-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-23
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty