Provider Demographics
NPI:1225759764
Name:REVIVE INJURY & WELLNESS
Entity Type:Organization
Organization Name:REVIVE INJURY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHANEL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BALAJADIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:725-216-7859
Mailing Address - Street 1:2931 N TENAYA WAY STE 204
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0458
Mailing Address - Country:US
Mailing Address - Phone:725-216-7859
Mailing Address - Fax:725-216-7859
Practice Address - Street 1:2931 N TENAYA WAY STE 204
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0458
Practice Address - Country:US
Practice Address - Phone:725-216-7859
Practice Address - Fax:725-216-7859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty