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General NPI Number Information
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NPI Number | 1790653533
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Entity Type | Organization
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Legal Business Name | REVIVAL WELLNESS LLC
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Dates
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Enumeration Date | 10/24/2025
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Last Update Date | 10/24/2025
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Provider Practice Location Address
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Address Line | 511 OREGON AVE PDT SUITE B3
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City | MORRIS
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State | MN
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Zip | 56267
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Country | US
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Telephone | 320-491-0594
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Fax | 320-491-0594
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Provider Business Mailing Address
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Address Line | 511 OREGON AVE
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City | MORRIS
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State | MN
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Zip | 56267-3712
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Country | US
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Telephone | 320-491-0594
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Fax | 320-491-0594
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Authorized Official
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Title or Position | CEO
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Name | NATHAN BRYANT MALEK
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Credential | CNP
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Telephone | 320-491-0594
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number |
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License Number State |
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