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General NPI Number Information
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NPI Number | 1326712100
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Entity Type | Organization
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Legal Business Name | REVIVE SPA HYDRATION PLLC
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Dates
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Enumeration Date | 08/04/2021
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Last Update Date | 08/06/2021
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Provider Practice Location Address
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Address Line | 17609 29TH AVENUE CT E
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City | TACOMA
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State | WA
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Zip | 98445-4622
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Country | US
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Telephone | 253-257-8340
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Fax |
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Provider Business Mailing Address
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Address Line | 17609 29TH AVENUE CT E
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City | TACOMA
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State | WA
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Zip | 98445-4622
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Country | US
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Telephone | 253-257-8340
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. BETH ANN SCHUBERT
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Credential | RN
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Telephone | 253-257-8340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WI0500X
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Taxonomy Name | Infusion Therapy Registered Nurse
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 163WN1003X
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Taxonomy Name | Nutrition Support Registered Nurse
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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