49D2269697 CLIA NUMBER - REVIVAL WELLNESS AND KETAMINE

Laboratory Demographics

  • CLIA Code: 49D2269697
  • Facility Name: REVIVAL WELLNESS AND KETAMINE
  • Facility Address: 4200-B TECHNOLOGY COURT
    CHANTILLY, VA
    ZIP 20151
  • Facility Phone: 703 988-3984
  • Facility Type: Other - IV THERAPY & KETAMINE INF
  • Facility Type: Waiver
  • Lab Director: NICOLE WATSON
  • NPI Number: 1093514655
  • Taxonomy: 261QM0801X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 49D2269697
LAB Type Other - IV THERAPY & KETAMINE INF
Facility Name REVIVAL WELLNESS AND KETAMINE
Street 4200-B TECHNOLOGY COURT
City CHANTILLY
State VA
ZIP 20151
Phone 703 988-3984
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/30/2024
Certificate Expiration Date 9/29/2026
Facility Type Other - IV THERAPY & KETAMINE INF
Lab Director NICOLE WATSON

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This page was last updated on: 9/29/2025