Provider Demographics
NPI:1508533209
Name:REVITALIZE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:REVITALIZE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-589-0821
Mailing Address - Street 1:4954 E POWERHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-5064
Mailing Address - Country:US
Mailing Address - Phone:208-589-0821
Mailing Address - Fax:
Practice Address - Street 1:4954 E POWERHOUSE DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406-5064
Practice Address - Country:US
Practice Address - Phone:208-589-0821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies