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General NPI Number Information
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NPI Number | 1518724624
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Entity Type | Organization
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Legal Business Name | REVIVE MEDICAL GROUP CA PC
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Dates
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Enumeration Date | 03/05/2024
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Last Update Date | 03/05/2024
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Provider Practice Location Address
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Address Line | 914 PINE ST
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City | MOUNT SHASTA
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State | CA
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Zip | 96067-2143
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Country | US
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Telephone | 203-430-1321
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Fax |
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Provider Business Mailing Address
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Address Line | 81 ROANOKE AVE
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City | FAIRFIELD
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State | CT
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Zip | 06824-6124
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Country | US
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Telephone | 203-430-1321
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Fax |
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Authorized Official
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Title or Position | CEO/MANAGER
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Name | OMAR ZIYADEH
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Credential |
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Telephone | 203-430-1321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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