Organization
CORE REVIVE / SOUL REVIVE LLC
Active
Other names
Core Revive
Organization subpart
No
Provider details
NPI number
Authorized official
PHILIP ANTHONY DIEHL RN (PARTNER)
(415) 250-7118
Entity
Organization
Contact information
Practice address
16 QUEENS LN, PETALUMA, CA 94952-1047
(707) 559-5347
Mailing address
16 QUEENS LN, PETALUMA, CA 94952-1047
(707) 559-5347
Taxonomy
Speciality
Code
Description
License number
State
163WD0400X
Diabetes Educator Registered Nurse
846331
CA
163WN1003X
Nutrition Support Registered Nurse
Primary
846331
CA
Other
Enumeration date
03/26/2018
Last updated
06/11/2019
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