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General NPI Number Information
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NPI Number | 1467175943
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Entity Type | Organization
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Legal Business Name | REVIVE MEDICAL SPA LLC
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Dates
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Enumeration Date | 09/21/2022
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Last Update Date | 09/21/2022
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Provider Practice Location Address
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Address Line | 1905 COWLES ST STE B
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City | FAIRBANKS
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State | AK
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Zip | 99701-5914
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Country | US
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Telephone | 907-371-1766
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Fax | 907-531-7365
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Provider Business Mailing Address
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Address Line | 1905 COWLES ST STE B
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City | FAIRBANKS
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State | AK
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Zip | 99701-5914
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Country | US
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Telephone | 907-371-1766
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Fax | 907-531-7365
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Authorized Official
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Title or Position | OWNER/PARTNER/NURSE PRACTITIONER
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Name | DR. KAROLINA PRIEBE
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Credential | DNP
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Telephone | 907-371-1766
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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