Healthcare Provider Details

I. General information

NPI: 1417827965
Provider Name (Legal Business Name): REVIVE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12306 QUAIL OAK CT
ASHLAND VA
23005-7871
US

IV. Provider business mailing address

12306 QUAIL OAK CT
ASHLAND VA
23005-7871
US

V. Phone/Fax

Practice location:
  • Phone: 804-852-2847
  • Fax: 434-217-1647
Mailing address:
  • Phone: 804-852-2847
  • Fax: 434-217-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. BESSEM OJONG ADESO
Title or Position: DIRECTOR
Credential: NP
Phone: 804-852-2847