Healthcare Provider Details

I. General information

NPI: 1346963667
Provider Name (Legal Business Name): REVIVE SPINE AND PAIN CARE CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11770 HAYNES BRIDGE RD UNIT 205-310
ALPHARETTA GA
30009-1966
US

IV. Provider business mailing address

270 BEACON KNOLL DR
ALPHARETTA GA
30022-6441
US

V. Phone/Fax

Practice location:
  • Phone: 616-634-5365
  • Fax:
Mailing address:
  • Phone: 616-634-5365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JADA J'NENE TRASHON REESE
Title or Position: OWNER
Credential: MD
Phone: 616-634-5365