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General NPI Number Information
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NPI Number | 1609372838
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Entity Type | Organization
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Legal Business Name | REVIVE OF COLORADO, PLLC
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Dates
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Enumeration Date | 04/05/2018
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Last Update Date | 04/05/2018
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Provider Practice Location Address
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Address Line | 218 E CHEYENNE MOUNTAIN BLVD
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City | COLORADO SPRINGS
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State | CO
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Zip | 80906-3720
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Country | US
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Telephone | 719-396-3003
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Fax | 719-396-3003
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Provider Business Mailing Address
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Address Line | 218 E CHEYENNE MOUNTAIN BLVD
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City | COLORADO SPRINGS
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State | CO
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Zip | 80906-3720
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Country | US
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Telephone | 719-396-3003
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Fax | 719-396-3003
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Authorized Official
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Title or Position | CEO
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Name | DEIRDRE RAQUEL WOLF
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Credential | AGNP-C
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Telephone | 719-396-3003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | AG09170063
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License Number State | CO
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