Provider Demographics
NPI:1083310312
Name:DR. REVIVAJENNZ MED SPA, PLLC
Entity Type:Organization
Organization Name:DR. REVIVAJENNZ MED SPA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS-GOERING
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-355-3566
Mailing Address - Street 1:4870 BIRKDALE DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9743
Mailing Address - Country:US
Mailing Address - Phone:734-355-3566
Mailing Address - Fax:
Practice Address - Street 1:418 S WAGNER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-1944
Practice Address - Country:US
Practice Address - Phone:734-355-3566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center