Healthcare Provider Details

I. General information

NPI: 1023816774
Provider Name (Legal Business Name): REVIVE SURGICENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1347 E SAMPLE RD STE 102
POMPANO BEACH FL
33064-6278
US

IV. Provider business mailing address

1347 E SAMPLE RD STE 102
POMPANO BEACH FL
33064-6278
US

V. Phone/Fax

Practice location:
  • Phone: 314-283-8738
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANE POHLMAN
Title or Position: OWNER
Credential: DO
Phone: 314-283-8738