MEDICARE: REVIVE WELLNESS CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0800X	Recovery Care Clinic/Center

General Provider Information

NPI Number	:	1235939612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE WELLNESS CENTER INC

Provider Business Mailing Address
First Line	:	2704 14TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1127
Country	:	US
Telephone Number	:	612-987-2990
Fax Number	:	612-987-2990

Provider Business Practice Location Address
First Line	:	2704 14TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1127
Country	:	US
Telephone Number	:	612-987-2990
Fax Number	:	612-987-2990

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANWAR MUSTAFA ABUKAR
Credential	:
Telephone Number	:	612-707-6834

Provider Enumeration Date	:	03/15/2025
Last Update Date	:	03/15/2025

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