Provider Demographics
NPI:1225627920
Name:REVIVE HYDRATION SPA LLC-S
Entity Type:Organization
Organization Name:REVIVE HYDRATION SPA LLC-S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:317-245-7353
Mailing Address - Street 1:5650 S FRANKLIN RD STE 300C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-8620
Mailing Address - Country:US
Mailing Address - Phone:317-245-7353
Mailing Address - Fax:317-527-9214
Practice Address - Street 1:5650 S FRANKLIN RD STE 300C
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-8620
Practice Address - Country:US
Practice Address - Phone:317-245-7353
Practice Address - Fax:317-527-9214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-16
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1619237476Medicaid