Provider Demographics
NPI:1518460047
Name:REVIVE CLINIC LLC
Entity Type:Organization
Organization Name:REVIVE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-392-3300
Mailing Address - Street 1:13316 S WESTERN AVE STE F
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-7309
Mailing Address - Country:US
Mailing Address - Phone:405-703-8882
Mailing Address - Fax:405-237-3799
Practice Address - Street 1:13316 S WESTERN AVE STE F
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-7309
Practice Address - Country:US
Practice Address - Phone:405-703-8882
Practice Address - Fax:405-237-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center