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General NPI Number Information
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NPI Number | 1164070009
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Entity Type | Organization
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Legal Business Name | VITAM REVIVERE CORPORATION
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Dates
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Enumeration Date | 09/03/2019
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Last Update Date | 09/03/2019
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Provider Practice Location Address
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Address Line | 327 COLLEGE ST STE 206
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City | WOODLAND
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State | CA
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Zip | 95695-3484
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Country | US
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Telephone | 916-288-7484
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Fax |
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Provider Business Mailing Address
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Address Line | 327 COLLEGE ST STE 206
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City | WOODLAND
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State | CA
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Zip | 95695-3484
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Country | US
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Telephone | 916-288-7484
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. DONALD ROBERT SIGGINS
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Credential | ED.D.
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Telephone | 530-591-7284
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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