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General NPI Number Information
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NPI Number | 1578249942
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Entity Type | Organization
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Legal Business Name | REVIVE CLINIC AND IV THERAPY LLC
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Dates
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Enumeration Date | 06/22/2023
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Last Update Date | 09/19/2023
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Provider Practice Location Address
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Address Line | 5631 BURKE CENTRE PKWY STE C
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City | BURKE
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State | VA
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Zip | 22015-2234
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Country | US
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Telephone | 703-200-1015
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Fax |
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Provider Business Mailing Address
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Address Line | 5631 BURKE CENTRE PKWY STE C
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City | BURKE
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State | VA
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Zip | 22015-2234
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | MICHELLE BUTLER
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Credential |
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Telephone | 916-909-4910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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