Provider Demographics
NPI:1659147486
Name:REVIVECARE MEDICAL & WELLNESS LLC
Entity Type:Organization
Organization Name:REVIVECARE MEDICAL & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:
Authorized Official - First Name:TIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:DORON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:407-300-8768
Mailing Address - Street 1:1534 BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4015
Mailing Address - Country:US
Mailing Address - Phone:407-300-8768
Mailing Address - Fax:
Practice Address - Street 1:2925 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-6459
Practice Address - Country:US
Practice Address - Phone:321-209-2203
Practice Address - Fax:888-344-9692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center