Provider Demographics
NPI:1750003323
Name:CLINICA REVIVE SALUD PLLC
Entity type:Organization
Organization Name:CLINICA REVIVE SALUD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NUBIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LOMELI
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C
Authorized Official - Phone:602-892-0799
Mailing Address - Street 1:6524 W INDIAN SCHOOL RD STE A
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033-3329
Mailing Address - Country:US
Mailing Address - Phone:602-892-0799
Mailing Address - Fax:602-892-0828
Practice Address - Street 1:6524 W INDIAN SCHOOL RD STE A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-3329
Practice Address - Country:US
Practice Address - Phone:602-892-0799
Practice Address - Fax:602-892-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care