Provider Demographics
NPI:1619415072
Name:REVIVE SALON AND SPA
Entity Type:Organization
Organization Name:REVIVE SALON AND SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MARY LYNN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:EICHERT
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:704-516-6782
Mailing Address - Street 1:4328 MOUNT HUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-4738
Mailing Address - Country:US
Mailing Address - Phone:704-516-6782
Mailing Address - Fax:
Practice Address - Street 1:5965 VILLAGE WAY
Practice Address - Street 2:E207
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2475
Practice Address - Country:US
Practice Address - Phone:619-293-7233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005931363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty