Healthcare Provider Details

I. General information

NPI: 1649347360
Provider Name (Legal Business Name): REVIVE WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 11/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 WHALLEY AVE
NEW HAVEN CT
06515-1728
US

IV. Provider business mailing address

867 WHALLEY AVE
NEW HAVEN CT
06515-1728
US

V. Phone/Fax

Practice location:
  • Phone: 203-387-1540
  • Fax: 203-387-8151
Mailing address:
  • Phone: 203-387-1540
  • Fax: 203-387-8151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number205
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number240
License Number StateCT

VIII. Authorized Official

Name: EMMANUEL SERGENTAKIS
Title or Position: OWNER
Credential:
Phone: 203-387-1540