Provider Demographics
NPI:1114595824
Name:REVIV PLLC
Entity type:Organization
Organization Name:REVIV PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:JOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-526-6530
Mailing Address - Street 1:3029 BRANDT DR S STE A
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-9140
Mailing Address - Country:US
Mailing Address - Phone:701-566-5306
Mailing Address - Fax:
Practice Address - Street 1:3029 BRANDT DR S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-9140
Practice Address - Country:US
Practice Address - Phone:701-566-5306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty