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General NPI Number Information
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NPI Number | 1467073098
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Entity Type | Organization
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Legal Business Name | REVIVE MEDICAL SUPPLIES
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Dates
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Enumeration Date | 05/05/2020
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Last Update Date | 01/04/2023
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Provider Practice Location Address
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Address Line | 1617 S BURLINGTON AVE
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City | LOS ANGELES
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State | CA
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Zip | 90006-2567
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Country | US
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Telephone | 949-390-9105
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 811457
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City | LOS ANGELES
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State | CA
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Zip | 90081-0008
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Country | US
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Telephone | 949-390-9105
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | CORY JACOBSEN
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Credential | MBA
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Telephone | 949-390-9105
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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