Provider Demographics
NPI:1710429808
Name:REVIVE ACUPUNCTURE INCORPORATED
Entity Type:Organization
Organization Name:REVIVE ACUPUNCTURE INCORPORATED
Other - Org Name:REVIVE ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACUPUNCTURIST, OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUPHIN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:831-428-5785
Mailing Address - Street 1:43353 MISSION BLVD # B
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-5828
Mailing Address - Country:US
Mailing Address - Phone:831-428-5785
Mailing Address - Fax:
Practice Address - Street 1:43353 MISSION BLVD # B
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-5828
Practice Address - Country:US
Practice Address - Phone:831-428-5785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13042171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty