Provider Demographics
NPI:1770930166
Name:REVIVE WELLNESS & REJUVENATION
Entity type:Organization
Organization Name:REVIVE WELLNESS & REJUVENATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-595-7836
Mailing Address - Street 1:13934 N 59TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4167
Mailing Address - Country:US
Mailing Address - Phone:602-595-7836
Mailing Address - Fax:602-419-2210
Practice Address - Street 1:13934 N 59TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4167
Practice Address - Country:US
Practice Address - Phone:602-595-7836
Practice Address - Fax:602-419-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty