Healthcare Provider Details

I. General information

NPI: 1922764067
Provider Name (Legal Business Name): REVIVERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 S. RANCHO SANTA FE RD. A-30
ENCINITAS CA
92024
US

IV. Provider business mailing address

162 S. RANCHO SANTA FE RD. A-30
ENCINITAS CA
92024
US

V. Phone/Fax

Practice location:
  • Phone: 858-956-0077
  • Fax:
Mailing address:
  • Phone: 858-956-0077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. STEVE LEISHER
Title or Position: OWNER
Credential:
Phone: 858-956-0077