Healthcare Provider Details

I. General information

NPI: 1790025203
Provider Name (Legal Business Name): AJUVA MEDICAL AESTHETICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9425 N NEVADA ST SUITE 300
SPOKANE WA
99218-5014
US

IV. Provider business mailing address

9425 N NEVADA ST SUITE 300
SPOKANE WA
99218-5014
US

V. Phone/Fax

Practice location:
  • Phone: 509-468-7546
  • Fax: 509-465-8886
Mailing address:
  • Phone: 509-468-7546
  • Fax: 509-465-8886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberM0045314
License Number StateWA

VIII. Authorized Official

Name: DR. DEBRA J RAVASIA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 509-465-8885