Provider Demographics
NPI:1669254710
Name:REVIVAL SKIN ARTISTRY
Entity type:Organization
Organization Name:REVIVAL SKIN ARTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KESNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-483-2006
Mailing Address - Street 1:10080 W 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-1429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10080 W 26TH AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-1429
Practice Address - Country:US
Practice Address - Phone:720-483-2006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty