Provider Demographics
NPI:1346911195
Name:REVITALIZE KETAMINE CLINIC LLC
Entity Type:Organization
Organization Name:REVITALIZE KETAMINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:DUBRAVCIC
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, PMHNP-BC
Authorized Official - Phone:928-213-6931
Mailing Address - Street 1:1800 S MILTON RD STE 26
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 S MILTON RD STE 26
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-6340
Practice Address - Country:US
Practice Address - Phone:928-213-6931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty