Healthcare Provider Details

I. General information

NPI: 1609061498
Provider Name (Legal Business Name): REVIVAMED MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 4TH AVE SUITE 200
SAN DIEGO CA
92101-6970
US

IV. Provider business mailing address

711 4TH AVE SUITE 200
SAN DIEGO CA
92101-6970
US

V. Phone/Fax

Practice location:
  • Phone: 619-232-3040
  • Fax: 619-232-3041
Mailing address:
  • Phone: 619-232-3040
  • Fax: 619-232-3041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA64593
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA50365
License Number StateCA

VIII. Authorized Official

Name: ROYA KOHANI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 619-232-3040