# REVIV PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1114595824
- **Authorized official:** MRS. LAURA LISA JOB (OPERATIONS MANAGER)
- **Authorized official phone:** (701) 526-6530

## Contact information

- **Practice address:** 3029 BRANDT DR S STE A, FARGO, ND 58104-9140
- **Practice address phone:** (701) 566-5306
- **Mailing address:** 3029 BRANDT DR S STE A, FARGO, ND 58104-9140
- **Mailing address phone:** (701) 566-5306

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | — | NULL | Yes |
| 208D00000X | General Practice Physician | — | — | Yes |
| 261QH0100X | Health Service Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 06/17/2021
- **Last updated:** 02/04/2025