Provider Demographics
NPI:1104185685
Name:REVITALIFE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:REVITALIFE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-913-5861
Mailing Address - Street 1:11402 OXBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-5491
Mailing Address - Country:US
Mailing Address - Phone:314-913-5861
Mailing Address - Fax:
Practice Address - Street 1:777 S NEW BALLAS RD
Practice Address - Street 2:STE 100E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8705
Practice Address - Country:US
Practice Address - Phone:314-913-5861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-03
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty