Healthcare Provider Details

I. General information

NPI: 1003637448
Provider Name (Legal Business Name): REVITALIZE WELLNESS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5170 N FLOYD AVE
FRESNO CA
93723
US

IV. Provider business mailing address

5170 N FLOYD AVE
FRESNO CA
93723-9435
US

V. Phone/Fax

Practice location:
  • Phone: 559-507-3760
  • Fax:
Mailing address:
  • Phone: 559-507-3760
  • Fax: 539-238-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHAZIA MALIK
Title or Position: OWNER
Credential:
Phone: 559-507-3760