Provider Demographics
NPI:1326712100
Name:REVIVE SPA HYDRATION PLLC
Entity Type:Organization
Organization Name:REVIVE SPA HYDRATION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SCHUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:253-257-8340
Mailing Address - Street 1:17609 29TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98445-4622
Mailing Address - Country:US
Mailing Address - Phone:253-257-8340
Mailing Address - Fax:
Practice Address - Street 1:17609 29TH AVENUE CT E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98445-4622
Practice Address - Country:US
Practice Address - Phone:253-257-8340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SECURE ALLIANCE PS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-04
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Single Specialty
No163WN1003XNursing Service ProvidersRegistered NurseNutrition SupportGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1609417203Medicaid