Provider Demographics
NPI:1659732683
Name:REVITALIZE HEALTH ACUPUNCTURE
Entity Type:Organization
Organization Name:REVITALIZE HEALTH ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIEM
Authorized Official - Middle Name:QUANG
Authorized Official - Last Name:LE-LAU
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM
Authorized Official - Phone:760-710-7836
Mailing Address - Street 1:503 E JACKSON ST # 224
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-4904
Mailing Address - Country:US
Mailing Address - Phone:760-710-7836
Mailing Address - Fax:
Practice Address - Street 1:10927 N 56TH ST
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-3000
Practice Address - Country:US
Practice Address - Phone:760-710-7836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty