Provider Demographics
NPI:1811339963
Name:REVIVE LOW T, LLC
Entity type:Organization
Organization Name:REVIVE LOW T, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NATUROPATHIC DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:206-960-4770
Mailing Address - Street 1:11903 NE 128TH ST
Mailing Address - Street 2:STE A
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034
Mailing Address - Country:US
Mailing Address - Phone:425-820-3800
Mailing Address - Fax:866-998-1837
Practice Address - Street 1:11911 NE 132ND ST STE 103
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2900
Practice Address - Country:US
Practice Address - Phone:206-960-4770
Practice Address - Fax:866-998-1837
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REVIVE LOW T LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-17
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60120417175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty