Provider Demographics
NPI:1679139778
Name:REVITALIZE HEALTH & WELLNESS LLC
Entity Type:Organization
Organization Name:REVITALIZE HEALTH & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:F
Authorized Official - Last Name:RITCHEY
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-583-8128
Mailing Address - Street 1:29702 SW TOWN CENTER LOOP W SUITE C
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-6481
Mailing Address - Country:US
Mailing Address - Phone:503-583-8128
Mailing Address - Fax:503-832-0366
Practice Address - Street 1:29702 SW TOWN CENTER LOOP W SUITE C
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-6481
Practice Address - Country:US
Practice Address - Phone:503-583-8128
Practice Address - Fax:503-832-0366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500734840Medicaid