MEDICARE: REVIVE LIFE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1041C0700X	Clinical Social Worker
2	2084P0800X	Psychiatry Physician
3	103T00000X	Psychologist
4	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1740081223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVIVE LIFE LLC

Provider Business Mailing Address
First Line	:	316 E DIAMOND AVE
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20877-3070
Country	:	US
Telephone Number	:	301-252-1866
Fax Number	:	301-345-3516

Provider Business Practice Location Address
First Line	:	316 E DIAMOND AVE
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20877-3070
Country	:	US
Telephone Number	:	206-898-5432
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	RADHIKA NATARAJ
Credential	:
Telephone Number	:	301-252-1866

Provider Enumeration Date	:	03/21/2025
Last Update Date	:	03/25/2026

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Directions to “REVIVE LIFE LLC ” Practice Location

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