Provider Demographics
NPI:1184252678
Name:REVIVE WELLNESS AND REJUVENATION LLC
Entity type:Organization
Organization Name:REVIVE WELLNESS AND REJUVENATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-595-7836
Mailing Address - Street 1:20229 N 67TH AVE STE C-A
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6664
Mailing Address - Country:US
Mailing Address - Phone:602-595-7836
Mailing Address - Fax:
Practice Address - Street 1:20229 N 67TH AVE STE C-A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6664
Practice Address - Country:US
Practice Address - Phone:602-595-7836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-30
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty