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General NPI Number Information
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NPI Number | 1013618255
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Entity Type | Organization
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Legal Business Name | REVIVE MEDICINE LLC
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Dates
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Enumeration Date | 03/14/2023
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Last Update Date | 03/14/2023
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Provider Practice Location Address
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Address Line | 3998 FAIR RIDGE DR STE 270
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City | FAIRFAX
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State | VA
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Zip | 22033-2907
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Country | US
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Telephone | 571-544-8110
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Fax |
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Provider Business Mailing Address
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Address Line | 5423 MARLSTONE LN
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City | FAIRFAX
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State | VA
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Zip | 22030-5834
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Country | US
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Telephone | 951-741-7258
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Fax |
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Authorized Official
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Title or Position | PRINCIPAL
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Name | DR. NANCY SELIM
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Credential | DO
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Telephone | 951-741-7258
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QB0002X
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Taxonomy Name | Obesity Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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