| Organization Name: | REVITALIZE WELLNESS CENTER |
| NPI Number: | 1215394119 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ROLAND MIGCHIELSEN (EXECUTIVE DIRECTOR) |
| Mailing Address: | 51577 Columbia River Hwy Suite C Scappoose |
| State: | OR US |
| Postal Code: | 970568409 |
| Phone Number: | 5033964807 |
| Fax Number: | 5033975373 |
| NPI Enumeration Date: | 01/22/2016 |
| NPI Last Update Date: | 01/22/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP3300X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Pain |
| Taxonomy Definition: | |