Healthcare Provider Details

I. General information

NPI: 1023949617
Provider Name (Legal Business Name): RE VIVIFY MD HEALTH AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

898 OAK ST SW
ATLANTA GA
30310-1959
US

IV. Provider business mailing address

898 OAK ST SW UNIT 3425
ATLANTA GA
30310-1974
US

V. Phone/Fax

Practice location:
  • Phone: 678-850-3509
  • Fax: 678-850-3509
Mailing address:
  • Phone: 678-850-3509
  • Fax: 678-850-3509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QP0002X
TaxonomyPhysician Nutrition Specialist (Family Medicine)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NIJAH BURRIS
Title or Position: FAMILY AND AESTHETIC MEDICINE
Credential: MD
Phone: 678-850-3509