Provider Demographics
NPI:1285311456
Name:REVAMP SERVICES INC
Entity type:Organization
Organization Name:REVAMP SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:MWANGI
Authorized Official - Suffix:
Authorized Official - Credentials:DNP-FNP-C
Authorized Official - Phone:206-327-8403
Mailing Address - Street 1:7705 S JUNETT ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-9026
Mailing Address - Country:US
Mailing Address - Phone:206-327-8403
Mailing Address - Fax:206-299-3342
Practice Address - Street 1:1702 S 72ND ST STE D
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-1238
Practice Address - Country:US
Practice Address - Phone:206-327-8403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-29
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1285311456OtherNPI