1730856659 NPI number — REVIVAL HEALTH MEDICAL GROUP PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730856659 NPI number — REVIVAL HEALTH MEDICAL GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVIVAL HEALTH MEDICAL GROUP PA
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:
1730856659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 N SEPULVEDA BLVD # 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANHATTAN BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90266-5111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-326-2029
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4661 WILSHIRE BLVD UNIT 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90010-3931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-326-2029
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
EUGENE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-326-2029

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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