Provider Demographics
NPI:1205139805
Name:REVITALIZED NATURAL HEALTH CENTER
Entity type:Organization
Organization Name:REVITALIZED NATURAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHILOMENA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARCUS
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:505-293-1658
Mailing Address - Street 1:720 LAMP POST CIR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-4115
Mailing Address - Country:US
Mailing Address - Phone:505-293-1658
Mailing Address - Fax:505-298-4737
Practice Address - Street 1:720 LAMP POST CIR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-4115
Practice Address - Country:US
Practice Address - Phone:505-293-1658
Practice Address - Fax:505-298-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR25188363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM94108897Medicaid
NMNM00RH90OtherBCBS OF NM
NM335732001Medicare PIN