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General NPI Number Information
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NPI Number | 1437941556
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Entity Type | Organization
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Legal Business Name | REVIVO MASSAGE LLC
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Dates
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Enumeration Date | 05/22/2025
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Last Update Date | 05/22/2025
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Provider Practice Location Address
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Address Line | 226 MASSACHUSETTS AVE
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City | ARLINGTON
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State | MA
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Zip | 02474-8435
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Country | US
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Telephone | 617-752-1710
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Fax |
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Provider Business Mailing Address
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Address Line | 107 GROVE ST
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City | MELROSE
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State | MA
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Zip | 02176-4631
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Country | US
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Telephone | 617-504-2262
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JAMAL THEODAT
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Credential |
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Telephone | 617-504-2262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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