Healthcare Provider Details

I. General information

NPI: 1447805544
Provider Name (Legal Business Name): REVIVE MEDICAL URGENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 N CLASSEN BLVD STE 100
OKLAHOMA CITY OK
73118-2426
US

IV. Provider business mailing address

PO BOX 57390
OKLAHOMA CITY OK
73157-7390
US

V. Phone/Fax

Practice location:
  • Phone: 405-673-7856
  • Fax: 619-374-7045
Mailing address:
  • Phone: 405-603-4901
  • Fax: 405-936-0561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEVIN BROWN
Title or Position: OWNER
Credential: DC
Phone: 951-440-1652