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Organization
REVITADERM PLLC
Active
Organization
REVITADERM PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BROOKE ASHLEY MACKIE PART OWNER (RN)
(817) 992-5066
Entity
Organization
Contact information
Practice address
110 CHEYENNE TRL S, NEWARK, TX 76071-3202
(817) 992-5066
Mailing address
PO BOX 1037, RHOME, TX 76078-1037
(817) 992-5066
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
—
—
Other
Enumeration date
01/27/2025
Last updated
01/27/2025
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