Provider Demographics
NPI:1255794921
Name:REVIVE HEARING LLC
Entity type:Organization
Organization Name:REVIVE HEARING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/HEARING INSTRUMENT SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ELI
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBEROW
Authorized Official - Suffix:
Authorized Official - Credentials:HIS
Authorized Official - Phone:971-202-5146
Mailing Address - Street 1:205 SE SPOKANE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6487
Mailing Address - Country:US
Mailing Address - Phone:541-678-1354
Mailing Address - Fax:
Practice Address - Street 1:11535 SW DURHAM RD
Practice Address - Street 2:C 3
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-3474
Practice Address - Country:US
Practice Address - Phone:503-430-8820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAS-P-10150569237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty