Provider Demographics
NPI:1699319988
Name:REVIVIFY DERMATOLOGY, LLC
Entity type:Organization
Organization Name:REVIVIFY DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GUEVARA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-877-8675
Mailing Address - Street 1:21301 POWERLINE RD STE 108
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-2388
Mailing Address - Country:US
Mailing Address - Phone:561-877-8675
Mailing Address - Fax:561-672-1365
Practice Address - Street 1:21301 POWERLINE RD # 108
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-2388
Practice Address - Country:US
Practice Address - Phone:561-877-8675
Practice Address - Fax:561-672-1365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty