Provider Demographics
NPI:1104644145
Name:REVIVE HEALTH AND AESTHETICS PC
Entity type:Organization
Organization Name:REVIVE HEALTH AND AESTHETICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEKUNLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FAJANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-735-3280
Mailing Address - Street 1:294 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-1838
Mailing Address - Country:US
Mailing Address - Phone:413-224-1009
Mailing Address - Fax:
Practice Address - Street 1:294 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1838
Practice Address - Country:US
Practice Address - Phone:413-224-1009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty