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General NPI Number Information
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NPI Number | 1679239180
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Entity Type | Organization
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Legal Business Name | REVIVE MEDICAL, PLLC
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Dates
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Enumeration Date | 11/10/2021
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Last Update Date | 12/15/2021
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Provider Practice Location Address
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Address Line | 12285 PELLICANO DRIVE SUITE A2
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City | EL PASO
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State | TX
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Zip | 79936
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Country | US
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Telephone | 915-248-4863
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Fax | 855-891-7827
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Provider Business Mailing Address
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Address Line | 12285 PELLICANO DRIVE SUITE A2
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City | EL PASO
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State | TX
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Zip | 79936
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Country | US
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Telephone | 915-248-4863
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Fax | 855-891-7827
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | CLIFFORD OWEN JANKE
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Credential | MD
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Telephone | 915-248-4863
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251F00000X
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Taxonomy Name | Home Infusion Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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Taxonomy #3
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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Taxonomy #4
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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Taxonomy #5
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Taxonomy Code | 333300000X
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Taxonomy Name | Emergency Response System Companies
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Taxonomy #6
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Taxonomy Code | 3416L0300X
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Taxonomy Name | Land Ambulance
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Taxonomy #7
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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Taxonomy #8
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Taxonomy Code | 363LX0106X
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Taxonomy Name | Occupational Health Nurse Practitioner
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Taxonomy #9
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Taxonomy Code | 261QE0002X
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Taxonomy Name | Emergency Care Clinic/Center
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