Provider Demographics
NPI:1508473000
Name:I-REVIVE PLLC
Entity Type:Organization
Organization Name:I-REVIVE PLLC
Other - Org Name:MY MEDICAL MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONVERSE
Authorized Official - Suffix:I
Authorized Official - Credentials:LMT, CIMT, CPMT
Authorized Official - Phone:616-377-8893
Mailing Address - Street 1:525 ELLIOTT AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1038
Mailing Address - Country:US
Mailing Address - Phone:616-377-8893
Mailing Address - Fax:616-607-8588
Practice Address - Street 1:525 ELLIOTT AVE
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1038
Practice Address - Country:US
Practice Address - Phone:616-566-1603
Practice Address - Fax:616-607-8588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI14997664OtherCAQH