MEDICARE: REVIVE INJECTION CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center

General Provider Information

NPI Number	:	1104784297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE INJECTION CLINIC

Provider Business Mailing Address
First Line	:	28207 TANGERINE LN
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91350-3257
Country	:	US
Telephone Number	:	818-536-8165
Fax Number	:	818-536-8165

Provider Business Practice Location Address
First Line	:	27833 AVENUE HOPKINS STE 6
Second Line	:
City	:	VALENCIA
State	:	CA
Zip	:	91355-4562
Country	:	US
Telephone Number	:	661-407-8507
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	JENNA GOODWIN
Credential	:	FNP-C
Telephone Number	:	818-536-8165

Provider Enumeration Date	:	01/15/2026
Last Update Date	:	01/15/2026

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Directions to “REVIVE INJECTION CLINIC ” Practice Location

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