Healthcare Provider Details

I. General information

NPI: 1558117622
Provider Name (Legal Business Name): REVIVE INFUSION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2226 LILIHA ST STE 304
HONOLULU HI
96817-1605
US

IV. Provider business mailing address

2226 LILIHA ST STE 304
HONOLULU HI
96817-1605
US

V. Phone/Fax

Practice location:
  • Phone: 808-699-8068
  • Fax: 808-229-1575
Mailing address:
  • Phone: 808-699-8068
  • Fax: 808-229-1575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYAN SMITH
Title or Position: OWNER
Credential: DO
Phone: 808-699-8068