Provider Demographics
NPI:1689467136
Name:REVITALIZE HEALTH CENTER LLC
Entity type:Organization
Organization Name:REVITALIZE HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEIVYS
Authorized Official - Middle Name:E
Authorized Official - Last Name:AVILA CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-443-8369
Mailing Address - Street 1:5285 SUMMERLIN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-7601
Mailing Address - Country:US
Mailing Address - Phone:786-359-4999
Mailing Address - Fax:786-359-4843
Practice Address - Street 1:5285 SUMMERLIN RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-7601
Practice Address - Country:US
Practice Address - Phone:786-359-4999
Practice Address - Fax:786-359-4843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty