Provider Demographics
NPI:1982237921
Name:REVIVE AESTHETICS & SPA WASILLA, LLC
Entity Type:Organization
Organization Name:REVIVE AESTHETICS & SPA WASILLA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-373-7546
Mailing Address - Street 1:1175 N LEATHERLEAF LOOP STE F
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6527
Mailing Address - Country:US
Mailing Address - Phone:907-373-7546
Mailing Address - Fax:907-373-7536
Practice Address - Street 1:1175 N LEATHERLEAF LOOP STE F
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6527
Practice Address - Country:US
Practice Address - Phone:907-373-7546
Practice Address - Fax:907-373-7536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center