Provider Demographics
NPI:1982413365
Name:REVIVE WELLNESS BAR LLC
Entity type:Organization
Organization Name:REVIVE WELLNESS BAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-FNP-C
Authorized Official - Prefix:MISS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:407-791-0613
Mailing Address - Street 1:3988 MAGENTA PL
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-6411
Mailing Address - Country:US
Mailing Address - Phone:407-791-0613
Mailing Address - Fax:
Practice Address - Street 1:3988 MAGENTA PL
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-6411
Practice Address - Country:US
Practice Address - Phone:407-791-0613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-31
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty