Provider Demographics
NPI:1194691931
Name:SL-CENTER OF REVITALIZING PSYCHIATRY
Entity type:Organization
Organization Name:SL-CENTER OF REVITALIZING PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGDIMUNOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-605-7469
Mailing Address - Street 1:9814 S CHYLENE DR STE 220
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-3557
Mailing Address - Country:US
Mailing Address - Phone:215-605-7469
Mailing Address - Fax:
Practice Address - Street 1:1935 E VINE ST STE 170
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84121-2197
Practice Address - Country:US
Practice Address - Phone:801-639-9833
Practice Address - Fax:801-639-9833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty