Provider Demographics
NPI:1467175943
Name:REVIVE MEDICAL SPA LLC
Entity Type:Organization
Organization Name:REVIVE MEDICAL SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER/NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAROLINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIEBE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:907-371-1766
Mailing Address - Street 1:1905 COWLES ST STE B
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5914
Mailing Address - Country:US
Mailing Address - Phone:907-371-1766
Mailing Address - Fax:907-531-7365
Practice Address - Street 1:1905 COWLES ST STE B
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5914
Practice Address - Country:US
Practice Address - Phone:907-371-1766
Practice Address - Fax:907-531-7365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty