Provider Demographics
NPI:1578249942
Name:REVIVE CLINIC AND IV THERAPY LLC
Entity Type:Organization
Organization Name:REVIVE CLINIC AND IV THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-909-4910
Mailing Address - Street 1:5631 BURKE CENTRE PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5631 BURKE CENTRE PKWY STE C
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-2234
Practice Address - Country:US
Practice Address - Phone:703-200-1015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-22
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty