Provider Demographics
NPI:1144256678
Name:REVITA HEALTH CENTER
Entity type:Organization
Organization Name:REVITA HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:QUEENIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MEI
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CTN
Authorized Official - Phone:847-981-8803
Mailing Address - Street 1:415 W GOLF RD
Mailing Address - Street 2:STE 3
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-3929
Mailing Address - Country:US
Mailing Address - Phone:847-981-8803
Mailing Address - Fax:847-981-8807
Practice Address - Street 1:415 W GOLF RD
Practice Address - Street 2:STE 3
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-3929
Practice Address - Country:US
Practice Address - Phone:847-981-8803
Practice Address - Fax:847-981-8807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU85951Medicare UPIN
IL211996Medicare ID - Type UnspecifiedREVITA HEALTH CENTER