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General NPI Number Information
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NPI Number | 1962149237
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Entity Type | Organization
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Legal Business Name | REVITALIZED, LLC
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Dates
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Enumeration Date | 05/17/2022
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Last Update Date | 05/17/2022
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Provider Practice Location Address
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Address Line | 4421 QUAIL RIDGE DR
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City | MINT HILL
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State | NC
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Zip | 28227-8236
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Country | US
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Telephone | 704-800-4980
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Fax |
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Provider Business Mailing Address
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Address Line | 4421 QUAIL RIDGE DR
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City | MINT HILL
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State | NC
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Zip | 28227-8236
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Country | US
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Telephone | 704-800-4980
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DANIEL FOWLER
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Credential |
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Telephone | 704-800-4980
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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