Organization
REVITALIZE KETAMINE CLINIC LLC
Active
Organization
REVITALIZE KETAMINE CLINIC LLC
Active
Other names
Revketa
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JILL MICHELLE DUBRAVCIC FNP, PMHNP-BC (OWNER/OPERATOR)
(928) 213-6931
Entity
Organization
Contact information
Practice address
1800 S MILTON RD STE 26, FLAGSTAFF, AZ 86001-6340
(928) 213-6931
Mailing address
1800 S MILTON RD STE 26, FLAGSTAFF, AZ 86001-6340
Taxonomy
Speciality
Code
Description
License number
State
261QM1300X
Multi-Specialty Clinic/Center
Primary
—
—
Other
Enumeration date
09/22/2021
Last updated
09/22/2021
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