Provider Demographics
NPI:1104536358
Name:REVIVE MEDICAL & AESTHETIC CLINIC
Entity type:Organization
Organization Name:REVIVE MEDICAL & AESTHETIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:UKENYE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:301-412-5522
Mailing Address - Street 1:7313 HANOVER PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3667
Mailing Address - Country:US
Mailing Address - Phone:301-412-5522
Mailing Address - Fax:301-498-7436
Practice Address - Street 1:7313 HANOVER PKWY STE A
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3667
Practice Address - Country:US
Practice Address - Phone:301-412-5522
Practice Address - Fax:301-498-7436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA