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General NPI Number Information
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NPI Number | 1730856659
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Entity Type | Organization
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Legal Business Name | REVIVAL HEALTH MEDICAL GROUP PA
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Dates
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Enumeration Date | 08/27/2021
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Last Update Date | 08/27/2021
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Provider Practice Location Address
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Address Line | 4661 WILSHIRE BLVD UNIT 105
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City | LOS ANGELES
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State | CA
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Zip | 90010-3931
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Country | US
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Telephone | 703-326-2029
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Fax |
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Provider Business Mailing Address
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Address Line | 1601 N SEPULVEDA BLVD # 103
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City | MANHATTAN BEACH
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State | CA
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Zip | 90266-5111
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Country | US
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Telephone | 703-326-2029
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EUGENE L. KIM
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Credential | MD
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Telephone | 703-326-2029
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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