Organization
REVIVE MD PLLC
Active
Organization
REVIVE MD PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ALFONSO MORALES MD (OWNER)
(651) 476-4412
Entity
Organization
Contact information
Practice address
821 RAYMOND AVE STE 230, SAINT PAUL, MN 55114-1503
(651) 746-4412
Mailing address
7595 CURRELL BLVD UNIT 25404, WOODBURY, MN 55125-2569
(612) 730-5196
(651) 647-1647
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
208VP0014X
Interventional Pain Medicine Physician
Primary
—
—
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
—
—
Other
Enumeration date
02/04/2021
Last updated
02/04/2021
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