Provider Demographics
NPI:1083210314
Name:REVITALIZE HEALTH LLC
Entity Type:Organization
Organization Name:REVITALIZE HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:WHNP-BC, CNM
Authorized Official - Phone:719-695-0756
Mailing Address - Street 1:13535 MORNING SKY CT
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-8392
Mailing Address - Country:US
Mailing Address - Phone:719-695-0756
Mailing Address - Fax:
Practice Address - Street 1:13535 MORNING SKY CT
Practice Address - Street 2:
Practice Address - City:PEYTON
Practice Address - State:CO
Practice Address - Zip Code:80831-8392
Practice Address - Country:US
Practice Address - Phone:719-695-0756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center