Provider Demographics
NPI:1639143647
Name:REVITALIZE WELLNESS CENTER
Entity Type:Organization
Organization Name:REVITALIZE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUBKEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-964-2577
Mailing Address - Street 1:502 N ANKENY BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-1755
Mailing Address - Country:US
Mailing Address - Phone:515-964-2577
Mailing Address - Fax:
Practice Address - Street 1:502 N ANKENY BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-1755
Practice Address - Country:US
Practice Address - Phone:515-964-2577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06104111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI15794Medicare ID - Type Unspecified