Healthcare Provider Details

I. General information

NPI: 1336988476
Provider Name (Legal Business Name): REVEAL MEDSPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 S 1040 W
PAYSON UT
84651-4614
US

IV. Provider business mailing address

969 S 640 E
PAYSON UT
84651-1628
US

V. Phone/Fax

Practice location:
  • Phone: 385-551-2929
  • Fax:
Mailing address:
  • Phone: 801-367-6049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. CHANTELLE ELMER
Title or Position: OWNER/PROVIDER
Credential: NP
Phone: 801-367-6049