Healthcare Provider Details

I. General information

NPI: 1174800452
Provider Name (Legal Business Name): REVIVEX HEALTHCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23510 CRENSHAW BLVD STE 100
TORRANCE CA
90505-5203
US

IV. Provider business mailing address

23150 CRENSHAW BLVD STE 100
TORRANCE CA
90505-3025
US

V. Phone/Fax

Practice location:
  • Phone: 310-437-7399
  • Fax: 310-437-7398
Mailing address:
  • Phone: 310-437-7399
  • Fax: 104-377-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. KARTIK ANANTH
Title or Position: PRESIDENT
Credential: MD
Phone: 310-437-7399