1346911195 NPI number — REVITALIZE KETAMINE CLINIC LLC

Table of content: (NPI 1346911195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346911195 NPI number — REVITALIZE KETAMINE CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REVITALIZE KETAMINE CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346911195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 S MILTON RD STE 26
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-6340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 S MILTON RD STE 26
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001-6340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-213-6931
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2021

Additional Information

Authorized Official

Authorized Official Last Name:
DUBRAVCIC
Authorized Official First Name:
JILL
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
928-213-6931

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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