Healthcare Provider Details

I. General information

NPI: 1780253500
Provider Name (Legal Business Name): REVIVE HEALTH CLINICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 E MISSOURI AVE STE 101
PHOENIX AZ
85014-2916
US

IV. Provider business mailing address

1839 S ALMA SCHOOL RD STE 354
MESA AZ
85210-3028
US

V. Phone/Fax

Practice location:
  • Phone: 602-296-4106
  • Fax: 602-296-4146
Mailing address:
  • Phone: 480-726-2287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA F BOCK
Title or Position: MANAGING MEMBER
Credential:
Phone: 480-726-2287