Healthcare Provider Details

I. General information

NPI: 1457896003
Provider Name (Legal Business Name): REVIVE SPINE AND PAIN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LINCOLN DR W STE E
MARLTON NJ
08053-1534
US

IV. Provider business mailing address

PO BOX 1126
ABSECON NJ
08201
US

V. Phone/Fax

Practice location:
  • Phone: 856-983-9001
  • Fax: 856-983-9011
Mailing address:
  • Phone: 856-983-9001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number25MA08922900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL RIZKALLA
Title or Position: DIRECTOR
Credential: MD
Phone: 856-983-9001