Provider Demographics
NPI:1629490388
Name:REVIVANATION LLC
Entity Type:Organization
Organization Name:REVIVANATION LLC
Other - Org Name:EYEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURBANK
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-765-5333
Mailing Address - Street 1:914 SW 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2001
Mailing Address - Country:US
Mailing Address - Phone:503-765-5333
Mailing Address - Fax:888-495-4549
Practice Address - Street 1:914 SW 11TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2001
Practice Address - Country:US
Practice Address - Phone:503-765-5333
Practice Address - Fax:888-495-4549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01286171100000X
OR17523225700000X
OR13830225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty