Provider Demographics
NPI:1659244143
Name:REVIVIFY BEAUTY SALON & SPA, LLC
Entity type:Organization
Organization Name:REVIVIFY BEAUTY SALON & SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABIGAIL
Authorized Official - Middle Name:AZALEA
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-205-9393
Mailing Address - Street 1:1600 THE OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-3829
Mailing Address - Country:US
Mailing Address - Phone:407-577-8136
Mailing Address - Fax:407-201-4460
Practice Address - Street 1:5041 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-5226
Practice Address - Country:US
Practice Address - Phone:407-205-9393
Practice Address - Fax:407-201-4460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier