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General NPI Number Information
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NPI Number | 1861058935
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Entity Type | Organization
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Legal Business Name | REVIVE TREATMENT CENTER INC
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Dates
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Enumeration Date | 05/14/2019
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Last Update Date | 05/14/2019
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Provider Practice Location Address
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Address Line | 1133 E WEST HWY APT 1515W
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City | SILVER SPRING
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State | MD
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Zip | 20910-6833
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Country | US
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Telephone | 301-760-3950
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Fax |
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Provider Business Mailing Address
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Address Line | 10125 COLESVILLE RD # 137
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City | SILVER SPRING
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State | MD
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Zip | 20901-2457
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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 | DIRECTOR
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Name | NICHOLAS ORSO
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Credential |
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Telephone | 301-760-3950
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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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