Healthcare Provider Details

I. General information

NPI: 1821910803
Provider Name (Legal Business Name): REVITALIZE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 NORTHWEST BLVD STE 200
COEUR D ALENE ID
83814-2973
US

IV. Provider business mailing address

4204 N MOCCASIN RD
COEUR D ALENE ID
83815-8826
US

V. Phone/Fax

Practice location:
  • Phone: 208-763-8920
  • Fax: 208-203-0947
Mailing address:
  • Phone: 208-763-8920
  • Fax: 208-763-8920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: HEATHER KING
Title or Position: CEO
Credential: FNP
Phone: 208-763-8920