Provider Demographics
NPI:1063172880
Name:REVIVIFY LLC
Entity type:Organization
Organization Name:REVIVIFY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMAYORCA
Authorized Official - Suffix:
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:908-273-2222
Mailing Address - Street 1:68 RIVER ROAD
Mailing Address - Street 2:ANNEX
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-1450
Mailing Address - Country:US
Mailing Address - Phone:908-273-2222
Mailing Address - Fax:
Practice Address - Street 1:68 RIVER ROAD
Practice Address - Street 2:ANNEX
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-1450
Practice Address - Country:US
Practice Address - Phone:908-273-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty