Healthcare Provider Details

I. General information

NPI: 1114595824
Provider Name (Legal Business Name): REVIV PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3029 BRANDT DR S STE A
FARGO ND
58104-9140
US

IV. Provider business mailing address

3029 BRANDT DR S STE A
FARGO ND
58104-9140
US

V. Phone/Fax

Practice location:
  • Phone: 701-566-5306
  • Fax:
Mailing address:
  • Phone: 701-566-5306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA LISA JOB
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 701-526-6530