Healthcare Provider Details

I. General information

NPI: 1669254710
Provider Name (Legal Business Name): REVIVAL SKIN ARTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10080 W 26TH AVE
LAKEWOOD CO
80215-1429
US

IV. Provider business mailing address

10080 W 26TH AVE
LAKEWOOD CO
80215-1429
US

V. Phone/Fax

Practice location:
  • Phone: 720-483-2006
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: CARLY D KESNER
Title or Position: OWNER
Credential:
Phone: 720-483-2006