Healthcare Provider Details

I. General information

NPI: 1710788294
Provider Name (Legal Business Name): REVITALIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2025
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 E 2ND ST STE 300
SCOTTSDALE AZ
85251-5627
US

IV. Provider business mailing address

7301 E 2ND ST STE 300
SCOTTSDALE AZ
85251-5627
US

V. Phone/Fax

Practice location:
  • Phone: 480-520-3223
  • Fax:
Mailing address:
  • Phone: 480-520-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: NATHAN JOWETT
Title or Position: DIRECTOR
Credential: MD, PHD
Phone: 480-520-3223