Core Revive / Soul Revive LLC

Primary specialty

Nutrition Support Registered NurseTaxonomy code 163WN1003X

License

846331 Issued in CA

Legal business name

CORE REVIVE / SOUL REVIVE LLC

Practice address

16 Queens LN
Petaluma, CA 94952-1047

Phone

(707) 559-5347

NPI assigned

Mar 26, 2018

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Philip Anthony Diehl, RN

Title

Partner

Phone

(415) 250-7118

Specialties & licenses 2

Addresses

Other names 1

• Core Revive Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1522022400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1560211200000",
    "number": "1154826980",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16 QUEENS LN",
            "city": "PETALUMA",
            "state": "CA",
            "postal_code": "949521047",
            "telephone_number": "707-559-5347"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16 QUEENS LN",
            "city": "PETALUMA",
            "state": "CA",
            "postal_code": "949521047",
            "telephone_number": "707-559-5347"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CORE REVIVE / SOUL REVIVE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-03-26",
        "last_updated": "2019-06-11",
        "status": "A",
        "authorized_official_last_name": "DIEHL",
        "authorized_official_first_name": "PHILIP",
        "authorized_official_middle_name": "ANTHONY",
        "authorized_official_title_or_position": "PARTNER",
        "authorized_official_telephone_number": "415-250-7118",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "163WD0400X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Registered Nurse, Diabetes Educator",
            "state": "CA",
            "license": "846331",
            "primary": false
        },
        {
            "code": "163WN1003X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Registered Nurse, Nutrition Support",
            "state": "CA",
            "license": "846331",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Core Revive",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Martha Lynn Coogan, LMFT
• Kellie Corcoran, MD
• Alek A Cordeiro
• Timothy Corder
• Ruby Arlene Cordingley
• Corinne Dobbas LLC
• Kelly Rodriguez Corley
• Julie Corralejo, PTA
• Elizabeth C Correll, LMHC
• Brandon Cortes

• Registered Nurse in Petaluma, CA
• Providers in Petaluma, CA by specialty
• Registered Nurse in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 11, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.