Provider Demographics
NPI:1093499915
Name:REVITAJUVE HEALTH AND BUSINESS, PLLC
Entity Type:Organization
Organization Name:REVITAJUVE HEALTH AND BUSINESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEREZIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:862-755-9075
Mailing Address - Street 1:526 N SAINT CLOUD ST # 1560
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-5041
Mailing Address - Country:US
Mailing Address - Phone:609-722-0071
Mailing Address - Fax:610-601-4749
Practice Address - Street 1:505 VISTA DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042-7210
Practice Address - Country:US
Practice Address - Phone:609-722-0071
Practice Address - Fax:610-601-4749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty