Healthcare Provider Details

I. General information

NPI: 1508749664
Provider Name (Legal Business Name): REVIVE5 PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N ORANGE AVE STE 710
ORLANDO FL
32801-5202
US

IV. Provider business mailing address

801 N ORANGE AVE STE 710
ORLANDO FL
32801-5202
US

V. Phone/Fax

Practice location:
  • Phone: 407-333-0496
  • Fax:
Mailing address:
  • Phone: 407-333-0496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. OSAMA SOUDAH
Title or Position: OWNER
Credential:
Phone: 714-476-6272