Provider Demographics
NPI:1679239180
Name:REVIVE MEDICAL, PLLC
Entity Type:Organization
Organization Name:REVIVE MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:OWEN
Authorized Official - Last Name:JANKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-248-4863
Mailing Address - Street 1:12285 PELLICANO DRIVE
Mailing Address - Street 2:SUITE A2
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936
Mailing Address - Country:US
Mailing Address - Phone:915-248-4863
Mailing Address - Fax:855-891-7827
Practice Address - Street 1:12285 PELLICANO DRIVE
Practice Address - Street 2:SUITE A2
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936
Practice Address - Country:US
Practice Address - Phone:915-248-4863
Practice Address - Fax:855-891-7827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No251F00000XAgenciesHome Infusion
No251S00000XAgenciesCommunity/Behavioral Health
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No291U00000XLaboratoriesClinical Medical Laboratory
No333300000XSuppliersEmergency Response System Companies
No3416L0300XTransportation ServicesAmbulanceLand TransportGroup - Multi-Specialty
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Multi-Specialty
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational HealthGroup - Multi-Specialty