1649110461 NPI number — REVIVE HEALTH CENTER LEHIGH CORP

Table of content: (NPI 1649110461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649110461 NPI number — REVIVE HEALTH CENTER LEHIGH CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVE HEALTH CENTER LEHIGH CORP
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:
1649110461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4019 W WATERS AVE STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33614-2333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-309-0604
Provider Business Mailing Address Fax Number:
954-388-0466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5598 8TH ST W UNIT 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEHIGH ACRES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33971-6341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-309-0604
Provider Business Practice Location Address Fax Number:
239-309-0604
Provider Enumeration Date:
03/31/2026

Additional Information

Authorized Official

Authorized Official Last Name:
FRIEDEBERG
Authorized Official First Name:
AARON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
239-309-0604

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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