Healthcare Provider Details

I. General information

NPI: 1760093025
Provider Name (Legal Business Name): REVITALIZED WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 E 8TH ST APT 206
SIOUX FALLS SD
57103-7038
US

IV. Provider business mailing address

401 E 8TH ST STE 214-7054
SIOUX FALLS SD
57103-7011
US

V. Phone/Fax

Practice location:
  • Phone: 605-423-7557
  • Fax: 605-305-1175
Mailing address:
  • Phone: 605-423-7557
  • Fax: 605-305-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: KRISTI LYNN ROSS
Title or Position: OWNER
Credential:
Phone: 605-423-7557