Provider Demographics
NPI:1467073098
Name:REVIVE MEDICAL SUPPLIES
Entity Type:Organization
Organization Name:REVIVE MEDICAL SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:949-390-9105
Mailing Address - Street 1:PO BOX 811457
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90081-0008
Mailing Address - Country:US
Mailing Address - Phone:949-390-9105
Mailing Address - Fax:
Practice Address - Street 1:1617 S BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2567
Practice Address - Country:US
Practice Address - Phone:949-390-9105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies