| Life Revival Llc | |
|
6404 Roosevelt Blvd Philadelphia PA 19149-2943 | |
| (267) 577-7747 | |
| Not Available |
| Full Name | Life Revival Llc |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 6404 Roosevelt Blvd, Philadelphia, Pennsylvania |
| Authorized Official Name and Position | Daniel Lee (DIRECTOR) |
| Authorized Official Contact | 2672594558 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Life Revival Llc 6404 Roosevelt Blvd Philadelphia PA 19149-2943 Ph: () - | Life Revival Llc 6404 Roosevelt Blvd Philadelphia PA 19149-2943 Ph: (267) 577-7747 |
| NPI Number | 1023701067 |
|---|---|
| Provider Enumeration Date | 05/26/2023 |
| Last Update Date | 02/11/2025 |
| Certification Date | 02/11/2025 |
| Medicare PECOS PAC ID | 3072034123 |
|---|---|
| Medicare Enrollment ID | O20250305004113 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1023701067 | NPI | - | NPPES |
| Provider Name | Abayomi O Ige |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1184620130 PECOS PAC ID: 4183648967 Enrollment ID: I20060119000422 |
| Provider Name | Kathleen Neil |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1861247876 PECOS PAC ID: 8820533607 Enrollment ID: I20240717000319 |
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