Provider Demographics
NPI:1609372838
Name:REVIVE OF COLORADO, PLLC
Entity Type:Organization
Organization Name:REVIVE OF COLORADO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEIRDRE
Authorized Official - Middle Name:RAQUEL
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:AGNP-C
Authorized Official - Phone:719-396-3003
Mailing Address - Street 1:218 E CHEYENNE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3720
Mailing Address - Country:US
Mailing Address - Phone:719-396-3003
Mailing Address - Fax:719-396-3003
Practice Address - Street 1:218 E CHEYENNE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3720
Practice Address - Country:US
Practice Address - Phone:719-396-3003
Practice Address - Fax:719-396-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAG09170063363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty