Provider Demographics
NPI:1760005771
Name:REVIVE PAIN CENTERS PA
Entity type:Organization
Organization Name:REVIVE PAIN CENTERS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:STUCKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-308-6190
Mailing Address - Street 1:14525 HIGHWAY 7 STE 375
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-3741
Mailing Address - Country:US
Mailing Address - Phone:651-308-6190
Mailing Address - Fax:
Practice Address - Street 1:14525 HIGHWAY 7 STE 375
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-3741
Practice Address - Country:US
Practice Address - Phone:651-308-6190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty