Provider Demographics
NPI:1730648304
Name:REVITALIZE WELLNESS GROUP CORP
Entity Type:Organization
Organization Name:REVITALIZE WELLNESS GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:R
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-786-9062
Mailing Address - Street 1:2715 SE MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7631
Mailing Address - Country:US
Mailing Address - Phone:503-786-9062
Mailing Address - Fax:
Practice Address - Street 1:29781 SW TOWN CENTER LOOP W STE 700
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-8901
Practice Address - Country:US
Practice Address - Phone:503-786-9062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty