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General NPI Number Information
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NPI Number | 1508488750
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Entity Type | Organization
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Legal Business Name | REVITALIZED FAMILY CARE
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Dates
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Enumeration Date | 05/11/2020
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Last Update Date | 05/11/2020
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Provider Practice Location Address
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Address Line | 673 PAULINE CT
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City | SONORA
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State | CA
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Zip | 95370-5216
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Country | US
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Telephone | 209-404-6746
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Fax |
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Provider Business Mailing Address
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Address Line | 4906 WEBSTER RD
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City | OAKDALE
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State | CA
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Zip | 95361-7850
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Country | US
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Telephone | 209-404-6746
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DAYNA IVERSON
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Credential | FNP
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Telephone | 209-404-6746
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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