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General NPI Number Information
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NPI Number | 1346963667
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Entity Type | Organization
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Legal Business Name | REVIVE SPINE AND PAIN CARE CENTER, PC
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Dates
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Enumeration Date | 09/21/2022
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Last Update Date | 10/13/2022
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Provider Practice Location Address
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Address Line | 11770 HAYNES BRIDGE RD UNIT 205-310
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City | ALPHARETTA
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State | GA
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Zip | 30009-1966
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Country | US
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Telephone | 616-634-5365
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Fax |
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Provider Business Mailing Address
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Address Line | 270 BEACON KNOLL DR
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City | ALPHARETTA
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State | GA
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Zip | 30022-6441
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Country | US
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Telephone | 616-634-5365
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JADA J'NENE TRASHON REESE
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Credential | MD
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Telephone | 616-634-5365
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State |
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