Basic Information
| Provider Information | |||||||||
| NPI: | 1225139439 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REVITA LIFE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4106 JOHN R | ||||||||
| Address2: | SUITE 805 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137457454 | ||||||||
| FaxNumber: | 3139938625 | ||||||||
| Practice Location | |||||||||
| Address1: | 4106 JOHN R | ||||||||
| Address2: | SUITE 805 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137457454 | ||||||||
| FaxNumber: | 3139938625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NUNN | ||||||||
| AuthorizedOfficialFirstName: | ANDRE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3137457454 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 132700000X | AN066667 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietary Manager |
No ID Information.