Provider Demographics
NPI:1962393306
Name:REVIVE AESTHETICS AND WELLNESS
Entity type:Organization
Organization Name:REVIVE AESTHETICS AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BASCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-822-1509
Mailing Address - Street 1:6140 28TH ST SE STE 105
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6140 28TH ST SE STE 105
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6938
Practice Address - Country:US
Practice Address - Phone:616-822-1509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty