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Organization
REVIVED MEDICAL IPA LLC
Active
Organization
REVIVED MEDICAL IPA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ILYA KIBLITSKY (SOLE MEMBER)
(917) 584-1409
Entity
Organization
Contact information
Practice address
1329 E 17TH ST, BROOKLYN, NY 11230-6052
(917) 584-1409
Mailing address
1329 E 17TH ST, BROOKLYN, NY 11230-6052
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
103T00000X
Psychologist
—
—
2084P0800X
Psychiatry Physician
Primary
—
—
225100000X
Physical Therapist
—
—
225X00000X
Occupational Therapist
—
—
Other
Enumeration date
05/19/2022
Last updated
05/19/2022
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