Provider Demographics
NPI:1225550551
Name:REVIVE LOW T, LLC
Entity Type:Organization
Organization Name:REVIVE LOW T, LLC
Other - Org Name:REVIVE LOW T CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:425-516-5500
Mailing Address - Street 1:11903 NE 128TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-7209
Mailing Address - Country:US
Mailing Address - Phone:425-820-3800
Mailing Address - Fax:866-998-1837
Practice Address - Street 1:720 S 320TH ST STE A
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5254
Practice Address - Country:US
Practice Address - Phone:206-960-4770
Practice Address - Fax:866-998-1837
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REVIVE LOW T, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60120417175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty