Provider Demographics
NPI:1609343797
Name:REVIVAL DME CORP
Entity Type:Organization
Organization Name:REVIVAL DME CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:GOWDY
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-490-3751
Mailing Address - Street 1:4025 CAMINO DEL RIO S STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4108
Mailing Address - Country:US
Mailing Address - Phone:619-542-7738
Mailing Address - Fax:
Practice Address - Street 1:4025 CAMINO DEL RIO S STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4108
Practice Address - Country:US
Practice Address - Phone:619-542-7738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-27
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies