=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508533209
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVITALIZE MEDICAL SUPPLY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2021
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1680 ELK CREEK DR # 2
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-1225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-757-4325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4954 E POWERHOUSE DR
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83406-5064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-589-0821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WHITNEY WHITWORTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-589-0821
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------