Provider Demographics
NPI:1902589369
Name:LAROCHE REVIVAL
Entity Type:Organization
Organization Name:LAROCHE REVIVAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-723-6289
Mailing Address - Street 1:12239 PINELANDS PARK LN
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-1539
Mailing Address - Country:US
Mailing Address - Phone:281-723-6289
Mailing Address - Fax:
Practice Address - Street 1:12239 PINELANDS PARK LN
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-1539
Practice Address - Country:US
Practice Address - Phone:281-723-6289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty