Provider Demographics
NPI:1790653533
Name:REVIVAL WELLNESS LLC
Entity type:Organization
Organization Name:REVIVAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:BRYANT
Authorized Official - Last Name:MALEK
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:320-491-0594
Mailing Address - Street 1:511 OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-3712
Mailing Address - Country:US
Mailing Address - Phone:320-491-0594
Mailing Address - Fax:320-491-0594
Practice Address - Street 1:511 OREGON AVE PDT SUITE B3
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267
Practice Address - Country:US
Practice Address - Phone:320-491-0594
Practice Address - Fax:320-491-0594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-24
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty