Provider Demographics
NPI:1013618255
Name:REVIVE MEDICINE LLC
Entity Type:Organization
Organization Name:REVIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SELIM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:951-741-7258
Mailing Address - Street 1:5423 MARLSTONE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5834
Mailing Address - Country:US
Mailing Address - Phone:951-741-7258
Mailing Address - Fax:
Practice Address - Street 1:3998 FAIR RIDGE DR STE 270
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2907
Practice Address - Country:US
Practice Address - Phone:571-544-8110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty