Provider Demographics
NPI:1942079231
Name:REVIVE CLINIC AND IV THERAPY LLC
Entity type:Organization
Organization Name:REVIVE CLINIC AND IV THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIERCTOR
Authorized Official - Prefix:
Authorized Official - First Name:GURDEV
Authorized Official - Middle Name:
Authorized Official - Last Name:SINGH
Authorized Official - Suffix:
Authorized Official - Credentials:DIRECTOR
Authorized Official - Phone:703-585-4942
Mailing Address - Street 1:7000 INFANTRY RIDGE RD STE 110A
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2370
Mailing Address - Country:US
Mailing Address - Phone:703-828-8089
Mailing Address - Fax:
Practice Address - Street 1:7000 INFANTRY RIDGE RD STE 110A
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2370
Practice Address - Country:US
Practice Address - Phone:703-828-8089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare