Provider Demographics
NPI:1093066045
Name:REVITA HEALTHCARE, LLC
Entity Type:Organization
Organization Name:REVITA HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONSUELO
Authorized Official - Middle Name:LAGASCA
Authorized Official - Last Name:DUMAYAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-380-6253
Mailing Address - Street 1:120 W GOLF RD STE 210
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60195-5161
Mailing Address - Country:US
Mailing Address - Phone:847-380-6253
Mailing Address - Fax:847-947-2786
Practice Address - Street 1:120 W GOLF RD STE 210
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60195-5161
Practice Address - Country:US
Practice Address - Phone:847-380-6253
Practice Address - Fax:847-947-2786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-29
Last Update Date:2012-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1011579251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health