Life Revival Llc
Legal Business Name
Life Revival Llc
NPI Number
1023701067
NPI Type
Organization
Enumeration Date
05/26/2023
Specialties
(Taxonomies)Name
Code
2084P0804X
1041C0700X
103TC1900X
103TF0000X
103TP2701X
101YM0800X
363LP0808X
2084P0800X
103TP0814X
Primary Taxonomy
No
No
No
No
No
No
No
No
No
Contact
Information
Purpose
Mailing
Location
Address
6404 ROOSEVELT BLVD
6404 ROOSEVELT BLVD
City
Philadelphia
Philadelphia
State
PA
PA
Postal Code
19149-2943
19149-2943
Country
US
US
Telephone Number
N/A
(267) 577-7747
Authorized Official
Name
Dr. Daniel Lee
Title or Position
DIRECTOR
Telephone Number
(267) 259-4558
Provider data last refreshed from NPPES NPI registry on 11/19/2024
Data last updated by provider on 05/26/2023