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General NPI Number Information
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NPI Number | 1104644145
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Entity Type | Organization
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Legal Business Name | REVIVE HEALTH AND AESTHETICS PC
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Dates
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Enumeration Date | 09/30/2024
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Last Update Date | 09/30/2024
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Provider Practice Location Address
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Address Line | 294 N MAIN ST
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City | EAST LONGMEADOW
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State | MA
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Zip | 01028-1838
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Country | US
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Telephone | 413-224-1009
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Fax |
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Provider Business Mailing Address
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Address Line | 294 N MAIN ST
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City | EAST LONGMEADOW
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State | MA
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Zip | 01028-1838
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Country | US
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Telephone | 413-224-1009
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ADEKUNLE A. FAJANA
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Credential | MD
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Telephone | 508-735-3280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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