Provider Demographics
NPI:1174800452
Name:REVIVEX HEALTHCARE INC
Entity type:Organization
Organization Name:REVIVEX HEALTHCARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KARTIK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANANTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-437-7399
Mailing Address - Street 1:23150 CRENSHAW BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3025
Mailing Address - Country:US
Mailing Address - Phone:310-437-7399
Mailing Address - Fax:104-377-3993
Practice Address - Street 1:23510 CRENSHAW BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5203
Practice Address - Country:US
Practice Address - Phone:310-437-7399
Practice Address - Fax:310-437-7398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TC0700X, 208100000X, 2084P0800X, 208VP0014X, 2084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFQ976AMedicare PIN