Provider Demographics
NPI:1023825999
Name:REVIVAL ACUPUNCTURE CLINIC LLC
Entity type:Organization
Organization Name:REVIVAL ACUPUNCTURE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:RHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:301-747-5336
Mailing Address - Street 1:4277 SLEEPY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2864
Mailing Address - Country:US
Mailing Address - Phone:301-747-5336
Mailing Address - Fax:571-667-4132
Practice Address - Street 1:4277 SLEEPY LAKE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2864
Practice Address - Country:US
Practice Address - Phone:301-747-5336
Practice Address - Fax:571-667-4132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-14
Last Update Date:2024-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty