# REVITALIZE PAIN AND SPINE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1346848090
- **Authorized official:** AMY WILLIAMS (DIRECTOR)
- **Authorized official phone:** (480) 969-4040

## Contact information

- **Practice address:** 4838 E BASELINE RD STE 110, MESA, AZ 85206-4674
- **Practice address phone:** (480) 210-2641
- **Practice address fax:** (480) 210-2642
- **Mailing address:** 4838 E BASELINE RD STE 110, MESA, AZ 85206-4674
- **Mailing address phone:** (480) 210-2641
- **Mailing address fax:** (480) 210-2642

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | — | NULL | — |
| 174400000X | Specialist | — | — | — |
| 207LP2900X | Pain Medicine (Anesthesiology) Physician | — | NULL | — |
| 207LP2900X | Pain Medicine (Anesthesiology) Physician | — | — | — |
| 208VP0000X | Pain Medicine Physician | — | NULL | Yes |
| 208VP0000X | Pain Medicine Physician | — | — | Yes |
| 208VP0014X | Interventional Pain Medicine Physician | — | NULL | — |
| 208VP0014X | Interventional Pain Medicine Physician | — | — | — |
| 363L00000X | Nurse Practitioner | — | NULL | — |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 10/14/2020
- **Last updated:** 10/14/2020