Provider Demographics
NPI:1922425248
Name:REVIVE LOW T, LLC
Entity Type:Organization
Organization Name:REVIVE LOW T, LLC
Other - Org Name:REVIVE LOW T CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:AARVIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-960-4770
Mailing Address - Street 1:11911 NE 132ND ST STE 103
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2900
Mailing Address - Country:US
Mailing Address - Phone:206-960-4770
Mailing Address - Fax:866-998-1837
Practice Address - Street 1:11903 NE 128TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7209
Practice Address - Country:US
Practice Address - Phone:206-960-4770
Practice Address - Fax:866-998-1837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60120417175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty