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General NPI Number Information
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NPI Number | 1710788294
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Entity Type | Organization
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Legal Business Name | REVITALIS LLC
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Dates
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Enumeration Date | 03/21/2025
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Last Update Date | 03/21/2025
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Provider Practice Location Address
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Address Line | 7301 E 2ND ST STE 300
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City | SCOTTSDALE
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State | AZ
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Zip | 85251-5627
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Country | US
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Telephone | 480-520-3223
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Fax |
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Provider Business Mailing Address
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Address Line | 7301 E 2ND ST STE 300
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City | SCOTTSDALE
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State | AZ
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Zip | 85251-5627
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Country | US
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Telephone | 480-520-3223
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | NATHAN JOWETT
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Credential | MD, PHD
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Telephone | 480-520-3223
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YS0123X
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Taxonomy Name | Facial Plastic Surgery Physician
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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 | 207YX0905X
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Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
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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 | 207YX0007X
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Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
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License Number |
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License Number State |
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