Provider Demographics
NPI:1821819210
Name:REVIVE STEM
Entity type:Organization
Organization Name:REVIVE STEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-550-7795
Mailing Address - Street 1:11469 N BROADLEAF HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-5632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11469 N BROADLEAF HOLLOW LN
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-5632
Practice Address - Country:US
Practice Address - Phone:801-550-7795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy