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Revive Wellness and Aesthetics PLLC

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Company Details

Name: Revive Wellness and Aesthetics PLLC
Jurisdiction: Idaho
Legal type: Limited Liability Company (D)
Status: Active-Existing
Date of registration: 18 Apr 2021 (4 years ago)
Financial Date End: 30 Apr 2026
Entity Number: 4250368
Place of Formation: IDAHO
File Number: 759085
ZIP code: 83703
County: Ada County
Principal Address: 4253 N. SORREL PL BOISE, ID 83703
Mailing Address: 9962 W MEADOWLARK ST BOISE, ID 83704-2785

Agent

Name Role Address
Kelsey Martin Agent 9962 W. MEADOWLARK ST., BOISE, ID 83704

Manager

Name Role Address Appointed On
Kelsey Martin Manager 4253 N. SORREL PL, BOISE, ID 83703 2022-05-20

National Provider Identifier

NPI Number:
1548940752
Certification Date:
2023-07-21

Authorized Person:

Name:
KELSEY MARTIN
Role:
OWNER/NURSE PRACTITIONER
Phone:

Taxonomy:

Selected Taxonomy:
363LF0000X - Family Nurse Practitioner
Is Primary:
Yes

Contacts:

Filing

Filing Name Filing Number Filing date
Annual Report 0006207130 2025-04-14
Statement of Change of Business Mailing Address 0005946016 2024-10-20
Annual Report 0005682223 2024-04-06
Annual Report 0005135259 2023-03-03
Annual Report 0004754265 2022-05-20

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Date of last update: 08 Jul 2025

Sources: Idaho Secretary of State