Provider Demographics
NPI:1720554959
Name:REVIVE HEALTH AND INJURY CENTER, LLC
Entity Type:Organization
Organization Name:REVIVE HEALTH AND INJURY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF ENTITY
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-999-1815
Mailing Address - Street 1:333 N LIMESTONE ST STE 104
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-4250
Mailing Address - Country:US
Mailing Address - Phone:937-319-4343
Mailing Address - Fax:937-319-4344
Practice Address - Street 1:333 N LIMESTONE ST STE 104
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-4250
Practice Address - Country:US
Practice Address - Phone:937-319-4343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-15
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty