Provider Demographics
NPI:1588166094
Name:REVIVE REJUVENATION CENTER ANTI AGING REGENERATIVE CENTER INC
Entity type:Organization
Organization Name:REVIVE REJUVENATION CENTER ANTI AGING REGENERATIVE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-501-6278
Mailing Address - Street 1:7509 DRAPER AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4862
Mailing Address - Country:US
Mailing Address - Phone:858-352-6200
Mailing Address - Fax:858-362-7555
Practice Address - Street 1:7509 DRAPER AVE STE A
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4857
Practice Address - Country:US
Practice Address - Phone:858-352-6200
Practice Address - Fax:858-362-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-01
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty