Provider Demographics
NPI:1740981380
Name:REVAMP WELLNESS CENTER
Entity type:Organization
Organization Name:REVAMP WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIS
Authorized Official - Middle Name:CHEPKORIR
Authorized Official - Last Name:MUTEMBETE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:480-747-4623
Mailing Address - Street 1:410 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5212
Mailing Address - Country:US
Mailing Address - Phone:480-747-4623
Mailing Address - Fax:
Practice Address - Street 1:410 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-5212
Practice Address - Country:US
Practice Address - Phone:480-747-4623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-10
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health