Provider Demographics
NPI:1922478221
Name:REVIVE ORTHOPAEDIC INSTITUTE, INC
Entity Type:Organization
Organization Name:REVIVE ORTHOPAEDIC INSTITUTE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTIAL OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-295-2995
Mailing Address - Street 1:270 N EL CAMINO REAL STE F
Mailing Address - Street 2:STE 219
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2874
Mailing Address - Country:US
Mailing Address - Phone:760-295-2995
Mailing Address - Fax:760-295-2906
Practice Address - Street 1:6010 HIDDEN VALLEY RD
Practice Address - Street 2:STE 210
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-4213
Practice Address - Country:US
Practice Address - Phone:760-295-2995
Practice Address - Fax:760-295-2906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68137174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty