Provider Demographics
NPI:1104682590
Name:REVITALIZED WELLNESS
Entity type:Organization
Organization Name:REVITALIZED WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARMEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIPSCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-838-0652
Mailing Address - Street 1:539 W COMMERCE ST # 4182
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1043 MEADOW RUN DR
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-3599
Practice Address - Country:US
Practice Address - Phone:972-838-0652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty