Provider Demographics
NPI:1215394119
Name:REVITALIZE WELLNESS CENTER
Entity Type:Organization
Organization Name:REVITALIZE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-397-5211
Mailing Address - Street 1:PO BOX 1234
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-8234
Mailing Address - Country:US
Mailing Address - Phone:503-397-5211
Mailing Address - Fax:503-397-5373
Practice Address - Street 1:51577 COLUMBIA RIVER HWY
Practice Address - Street 2:SUITE C
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-8409
Practice Address - Country:US
Practice Address - Phone:503-396-4807
Practice Address - Fax:503-397-5373
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUMBIA COMMUNITY MENTAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-22
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain