Healthcare Provider Details

I. General information

NPI: 1699092395
Provider Name (Legal Business Name): REVIVE THERAPEUTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 S DAWSON ST STE 104
SEATTLE WA
98118-2100
US

IV. Provider business mailing address

5100 S DAWSON ST STE 104
SEATTLE WA
98118-2100
US

V. Phone/Fax

Practice location:
  • Phone: 206-760-1448
  • Fax: 206-760-1730
Mailing address:
  • Phone: 206-760-1448
  • Fax: 206-760-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number00000488
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number00023864
License Number StateWA

VIII. Authorized Official

Name: DANA KIRKWOOD-WATTS
Title or Position: OWNER
Credential:
Phone: 206-760-1448