Basic Information
| Provider Information | |||||||||
| NPI: | 1215394119 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REVITALIZE WELLNESS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1234 | ||||||||
| Address2: | |||||||||
| City: | SAINT HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970518234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033975211 | ||||||||
| FaxNumber: | 5033975373 | ||||||||
| Practice Location | |||||||||
| Address1: | 51577 COLUMBIA RIVER HWY | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SCAPPOOSE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970568409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033964807 | ||||||||
| FaxNumber: | 5033975373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2016 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | JACOBSON | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5033975211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLUMBIA COMMUNITY MENTAL HEALTH | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.