Provider Demographics
NPI:1093345969
Name:REVIVE NUTRITION LLC
Entity type:Organization
Organization Name:REVIVE NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SABADA
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:314-369-3159
Mailing Address - Street 1:3305 WASHINGTON ST UNIT 401
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-5322
Mailing Address - Country:US
Mailing Address - Phone:314-369-3159
Mailing Address - Fax:
Practice Address - Street 1:3305 WASHINGTON ST UNIT 401
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-5322
Practice Address - Country:US
Practice Address - Phone:314-369-3159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-20
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty