Provider Demographics
NPI:1619770005
Name:REVIVE FUNCTIONAL REHABILITATION CENTER
Entity type:Organization
Organization Name:REVIVE FUNCTIONAL REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:FAIRLEIGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-291-3618
Mailing Address - Street 1:25 MAR VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-3486
Mailing Address - Country:US
Mailing Address - Phone:850-291-3618
Mailing Address - Fax:
Practice Address - Street 1:3246 COVE BEND DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-2752
Practice Address - Country:US
Practice Address - Phone:850-291-3618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain