Healthcare Provider Details

I. General information

NPI: 1013618255
Provider Name (Legal Business Name): REVIVE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3998 FAIR RIDGE DR STE 270
FAIRFAX VA
22033-2907
US

IV. Provider business mailing address

5423 MARLSTONE LN
FAIRFAX VA
22030-5834
US

V. Phone/Fax

Practice location:
  • Phone: 571-544-8110
  • Fax:
Mailing address:
  • Phone: 951-741-7258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NANCY SELIM
Title or Position: PRINCIPAL
Credential: DO
Phone: 951-741-7258