Healthcare Provider Details

I. General information

NPI: 1790653533
Provider Name (Legal Business Name): REVIVAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2025
Last Update Date: 10/24/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 OREGON AVE PDT SUITE B3
MORRIS MN
56267
US

IV. Provider business mailing address

511 OREGON AVE
MORRIS MN
56267-3712
US

V. Phone/Fax

Practice location:
  • Phone: 320-491-0594
  • Fax: 320-491-0594
Mailing address:
  • Phone: 320-491-0594
  • Fax: 320-491-0594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NATHAN BRYANT MALEK
Title or Position: CEO
Credential: CNP
Phone: 320-491-0594