Provider Demographics
NPI:1548024698
Name:REVITALIZE MEDICAL AESTHETICS AND WELLNESS SPA
Entity type:Organization
Organization Name:REVITALIZE MEDICAL AESTHETICS AND WELLNESS SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF ENTITY
Authorized Official - Prefix:
Authorized Official - First Name:NIMALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-835-2209
Mailing Address - Street 1:3435 US HIGHWAY 9 UNIT 4
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-3285
Mailing Address - Country:US
Mailing Address - Phone:732-835-2209
Mailing Address - Fax:848-444-9218
Practice Address - Street 1:3435 US HIGHWAY 9 UNIT 4
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-3285
Practice Address - Country:US
Practice Address - Phone:732-835-2209
Practice Address - Fax:848-444-9218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-09
Last Update Date:2024-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty