1255209581 NPI number — REVIVE CLINIC LLC

Table of content: HECTOR ANDRE RIVERA RAMOS (NPI 1174391528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255209581 NPI number — REVIVE CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVE CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255209581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 L ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20036-4910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-328-4810
Provider Business Mailing Address Fax Number:
269-210-2598

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10101 TWIN RIVERS RD
Provider Second Line Business Practice Location Address:
APT 401
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-328-4810
Provider Business Practice Location Address Fax Number:
269-210-2598
Provider Enumeration Date:
10/28/2025

Additional Information

Authorized Official

Authorized Official Last Name:
CUFFEE
Authorized Official First Name:
DENISHA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
443-328-4810

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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