Provider Demographics
NPI:1326381583
Name:REVIVE NATUROPATHIC MEDICINE, INC.
Entity Type:Organization
Organization Name:REVIVE NATUROPATHIC MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:760-306-4842
Mailing Address - Street 1:4085 HARRISON ST
Mailing Address - Street 2:#3
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-3586
Mailing Address - Country:US
Mailing Address - Phone:503-577-8184
Mailing Address - Fax:
Practice Address - Street 1:560 CARLSBAD VILLAGE DR
Practice Address - Street 2:202C
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2391
Practice Address - Country:US
Practice Address - Phone:760-452-0763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-05
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA-560175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty