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General NPI Number Information
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NPI Number | 1104536358
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Entity Type | Organization
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Legal Business Name | REVIVE MEDICAL & AESTHETIC CLINIC
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Dates
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Enumeration Date | 11/29/2022
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Last Update Date | 11/29/2022
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Provider Practice Location Address
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Address Line | 7313 HANOVER PKWY STE A
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City | GREENBELT
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State | MD
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Zip | 20770-3667
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Country | US
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Telephone | 301-412-5522
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Fax | 301-498-7436
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Provider Business Mailing Address
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Address Line | 7313 HANOVER PKWY STE A
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City | GREENBELT
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State | MD
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Zip | 20770-3667
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Country | US
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Telephone | 301-412-5522
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Fax | 301-498-7436
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | FLORENCE UKENYE
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Credential | FNP
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Telephone | 301-412-5522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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