Provider Demographics
NPI:1538837737
Name:REVIVED MEDICAL SPA LLC
Entity type:Organization
Organization Name:REVIVED MEDICAL SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:678-559-2301
Mailing Address - Street 1:350 HILLGROVE DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8601
Mailing Address - Country:US
Mailing Address - Phone:404-551-6686
Mailing Address - Fax:
Practice Address - Street 1:350 HILLGROVE DR
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30114-8601
Practice Address - Country:US
Practice Address - Phone:404-551-6686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center